1. Autism Spectrum Disorders: Research findings and treatment implications C enter for A utism and R elated D isorders, Inc Doreen Granpeesheh, Ph.D. B.C.B.A-D

2. Today’s Presentations DSM 5 diagnosis of ASD A multi-disciplinary treatment model What is ABA (Applied Behavior Analysis) Applications of behavior analysis to the treatment of ASD

3. Autism Spectrum Disorder Doreen Granpeesheh, PhD, BCBA-D

4. DSM IV Autistic Disorder: Total of 6 or more symptoms < age 3  Social Deficits (2) Eye Contact Showing/Sharing Emotional Reciprocity  Communication Deficits Language Pretend Play Conversation  Stereotypic/Repetitive Behaviors Routines Preoccupation Intense focus Motor 4

5. DSM IV Asperger’s  Social Deficits: 2  Stereotypic/Repetitive: 1  No Communication Deficit PDDNOS  Same as Autistic Disorder but less than 6 symptoms 5

6. Autism Spectrum Disorder: DSM-5 Criterion A: Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifested by all 3 of the following: 1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction, 2. Deficits in non-verbal communicative behaviors used for social interaction; ranging from poorly integrated verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people

7. Autism Spectrum Disorder: DSM-5 Criterion B: Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases) 2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes). 3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects) (APA, 2011) 7

8. Autism Spectrum Disorder: DSM-5 Criterion C: Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) Criterion D: Symptoms together limit and impair everyday functioning 8

9. Key Differences Between DSM-IV-TR and DSM-5 3 key domains become 2 Shift from categorical to dimensional Requires 2 repetitive/restrictive behaviors Language delay is not necessary Specifiers and modifiers Level of severity 9

10. ASD DSM-5 Diagnosis: Specifiers and Modifiers With the new criteria, the child will receive a diagnosis with the etiology as a specifier  ASD with Rett Syndrome  ASD with Fragile X OR with a modifier indicating another important factor  ASD with tonic-clonic seizures  ASD with intellectual disabilities 10

11. ASD DSM-5 Diagnosis: Specifiers and Modifiers Early history is also specified  Age of perceived onset  Pattern of onset Loss of skills (when?)  ASD with onset before 20 months and loss of words  ASD with onset before 32 months and loss of social skills  ASD with no clear onset and no loss  ASD – Aspergers type 11

12. Level of Severity Severity Level for ASDSocial CommunicationRestricted interests & repetitive behaviors Level 1: Requiring Support Without support, some significant deficits in social communication Significant interference in at least one context Level 2: Requires substantial support Marked deficits with limited initiations and reduced or atypical responses Obvious to the casual observer and occur across contexts Level 3: Requires very substantial support Minimal social communication Marked interference in daily life 12

13. Social Communication Disorder Impaired pragmatic use of language Difficulty in the social use of verbal or nonverbal communication  Must affect development of relationships, comprehension, academic achievement, or occupational performance Cannot be explained by low cognitive ability, word structure, or grammar Symptoms must be present in early childhood  But may not fully manifest until social demands exceed capacities ASD must be ruled out 13

14. Clinical Implications ADHD can now be diagnosed along with ASD Need to rework assessment measures  Screeners and gold standard measures of assessments are based on DSM-IV criteria Services and third party billing 14

15. What does ASD look like? Communication:  delayed in language  no eye contact Social Behavior:  No interaction with anyone  Do not play with others  Do not ask for help Stereotypy:  Numerous repetitive behaviors (lining up objects, opening closing door, turning on and off the lights)  Many inflexibilities and repetitive routines Anything else? Challenging Behaviors! Sensory Sensitivities! Medical Illnesses!

16. Teach New Learning Patterns Genetic Predisposition Physical Conditions Oxidative Stress Decreased Methylation Immune Dysfunction GI Inflammation Brain Disorders Hypoperfusion Hypo and Hyper sensitivity to stimuli Different Learning Patterns Behavioral Symptoms Delayed Language Delayed Social Skills StereotypyAUTISM Metals Pesticides BisphenolA Antibiotics Minimize Exposure To Toxins Treat the Underlying Medical Disorders Identify Sensory Issues Reduce/Eliminate Symptoms

17. Minimize Exposure to Toxins Make sure your physician only uses antibiotics when necessary Avoid pesticides (go organic) Avoid BPA (plastics) Spread out vaccinations to reduce stress on immune system Check for metal toxicity to determine need for chelation (toxic metal assay)

18. Treat Underlying Medical Illness Immune Markers  Immunoglobulin Subsets (Antibodies that respond to bacteria, viruses, fungus, etc)  Check for Strep Titers (PANDAS)  Vaccine Titers Detoxification markers  Redox capacity (Redox SYS™ Diagnostic System).  Oxidative Stress  Decreased Methylation/transulfation (fasting plasma cysteine or methionine markers Discuss Possible Treatments with your physician

19. Treat Underlying Medical Illness Evaluate and Treat GI Disorders  Nutrition  Diet  Medication Anti-inflammatories Steroids Anti-fungals Anti Chlostridia

20. Help the child become healthy  Make sure he is sleeping well  Make sure he is getting the right nutrition

21. Identify Sensory Issues Everything we learn enters through our senses How does your child receive information?  Does he perceive visual information correctly? Focus versus double vision Binocularity Central Vision Tracking  Does he perceive auditory information correctly? Figure ground discrimination Binaural integration and separation Appropriate hemispheric lateralization  Does he perceive tactile or proprioceptive information correctly? If we don’t receive information correctly, we cannot learn correctly!

22. Visual Form Constancy

24. Visual Figure-Ground Discrimination

25. Treating sensory issues Developmental Optometry  Tracking  Figure ground discrimination  Bilateral use exercises Audiology  Pairing with visual input  Noise reduction headphones  Practice the hemispheric deficit areas Tactile/Proprioceptive  Sensory Integration/OT  Sensory Diet to regulate Sensory Regulation Activities  Teaching self soothing activities  Using environmental stimuli to prevent sensory overload

26. Experiencing the world through Autism Little or no sleep Stomach pain, bloating, discomfort Diarrhea and/or constipation Lights are too strong or piercing Sounds are too intense Background noise is loud Objects are not in focus Everything is unpredictable

27. Do individuals with autism experience anxiety? Signs of Anxiety in Autism  Self stimulatory behavior Ordering, lining up Hoarding Checking Avoiding  Social Activities  Eye Contact  Demands  Self injury?

28. Treat the Anxiety Reduce demands until skills are mastered Reward frequently Teach coping strategies Allow functional levels of compulsivity Improve Sleep Improve Chemistry  SSRI  SNRI

29. Teach New Learning Patterns ABA: Applied Behavior Analysis  “30 years of research demonstrated the efficacy of Applied Behavioral methods in reducing inappropriate behavior and in increasing communication, learning and appropriate social behavior” Surgeon General, 1999

30. Outcome Research on ABA for Autism Lovaas (1987) Sallows (2005) Howard (2005) Cohen (2006) Eikeseth (2007) Remington (2007) Perry (2008)

31. 1987: Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children Experimental Group: N=19 Control Group 2: N=20 Control Group 1: N=20 40 hours/wk 3 yrs 10 hours/wk 3 yrs 10 hours/wk UCLA/NPI 3 yrs 47% Recovered! 2% Recovered

32. 40 hrs/week ABA for 2 or more years 47% achieved average IQ and required no special education after treatment McEachin (1993): gains maintained for 8/9 when the children were 12 years old

33. 4 years of ABA Results:  Average IQ: 48%  Success in unsupported regular education: 34%  Non-impaired communication: 42%  Non-impaired socialization: 42%  Failure to qualify for autism according to the ADI-R: 34%

34. 3 years of ABA Results:  Average IQ: 57%  Success in unsupported regular education : 28%  Non-impaired on the Vineland adaptive behavior composite: 38%

35. Replication in Norway 2 years of ABA Results:  Average IQ: 7/13 = 54%  Average score on Aechenbach CBC: 4/13 = 31%

36. Replication in England 25 hrs/week of ABA for 2 years  Gains in language, intelligence, daily living, positive social behavior  No increase in parent stress

37. Replication in the Middle East Results:  Scoring in non-ASD range on ADOS after treatment: 4/19 = 21%

38. Whole province of Ontario, Canada Free ABA for all young children with autism 332 children 71% made significant gains 11% achieved functioning in the average range Poor quality control, lots of different providers, still had large good effects

39. Outcome Research on ABA for Autism Conclusions of outcome research  Every published study demonstrated very large treatment effects  Replicated across research groups, across university vs. community settings, and across continents  Intensity matters: at least 25 hours per week of one-to-one intervention for more than a year produces best outcomes  Duration matters: two or more years of intervention

40. Outcome-Level Analysis of ABA Treatment for Autism Effects of age and treatment intensity on outcome N = 245 More treatment = more gains Published in Research in Autism Spectrum Disorders (2009)

41. Recovery from Autism Retrospective analysis of charts in 38 cases of recovery following ABA treatment In-press in Annals of Clinical Psychiatry

42. Acceptability of ABA The following bodies now recommend ABA as a treatment for autism  American Academy of Pediatrics  The New York State Department of Health  The National Academy of Sciences  Surgeon General “30 years of research demonstrated the efficacy of Applied Behavioral methods in reducing inappropriate behavior and in increasing communication, learning and appropriate social behavior” Surgeon General, 1999

43. Integrative Treatment Sensory Interventions Develop and Regulate sensory input ability Behavioral Interventions Teach new learning patters Generalize to daily living Medical Interventions Eliminate Triggers Stabilize underlying cause Achieve health

44. Why would a behaviorist care about biomedical interventions? 1990: Andrew was diagnosed with Celiac…we placed him on a diet and he recovered within a year! 1992: I began to notice a pattern of children with extremely high use of antibiotics! This must be leading to some abnormal flora! 1993: Emily had fungus on her nails…treated with antifungals, her behavior changed drastically!

45. Preliminary Outcome Study:1996 63 boys16 girls 79 children Average age at intake: 39.1 months Average IQ at intake: 76.8 (borderline) Length of time in treatment: 3 years

46. Preliminary Outcome Study:1996 High Intensity More than 25 hours/week 44 children Low Intensity Less than 25 hours/week 35 children Matched on age, IQ, language, adaptive behavior

47. Results: Outcome 1996

48. Normal Cognitive Functioning

49. Why didn’t we publish this? 1996 Outcome Study Confounding Variable: A higher percentage of children in the high intensity group were receiving biomedical interventions! Was the improvement in IQ and adaptive skills due to ABA or due to the medical interventions or a combination???

50. Let’s look at some case studies of children who improved significantly with a combination of medical and behavioral treatment

51. D.R. Diagnosis: Autism Intake:  Age: 2.11  Deficits: receptive vocabulary of 10 words, 3 expressive words used for needs (juice, open, ball), no eye contact, severe tantrums, crying, aggression and elopement, ssb included gazing, mouthing objects and toe walking. Treatment:  1 year 10 months with CARD to date  Average intensity of 30 hours/week  Specific Carbohydrate Diet Current:  Age: 4.9  In typical preschool with aide  175 mastered receptive labels, mands and tacts with all items using full sentences, maintains eye contact up to 8 seconds, responds to name by making eye contact and saying “yes” or ‘what”, answers 23 social identification questions, interacts with adults average of 10 minutes/peers 2 minutes. Ssb reduced but still exist, aggression and noncompliance have extinguished.

52. D.R.: New Skills per month

53. D.R.: Stereotypy per month

54. D.R.: Aggression per month

55. Emma Diagnosis: Asperger’s Syndrome Intake:  Age: 3.4  Deficits: poor eye contact, extensive vocabulary but did not use language with peers, self-isolated at school, severe tantrums, non compliance and aggression with family, visual self-stimulatory behaviors, severe ritualistic behavior, no Theory of Mind Treatment:  10 months with CARD  Average intensity of 10 hours/week  Lexapro  Pro DHA and CorOmega Exit:  Age: 4.2  In typical kindergarten with no aide  Initiated conversations with peers, many friends, no tantrums or aggression, very advanced in academic skills and very popular in school

56. Emma: Challenging Behaviors per month

57. Emma: New Skills per month

58. A. D. Diagnosis: Autism Intake:  Age: 2.11  Deficits: had 3-4 word utterances but no spontaneous language, self- isolated around peers, no safety awareness, toe walking, licking hands, had difficulty inhibiting responses and would often touch people’s hair or clothing. Treatment:  3 year with CARD  Average intensity of 25 hours/week  Anti-fungals  Chelation Exit:  Age: 5.11  In typical kindergarten without aide  Initiates, joins, transitions conversations with peers, has many friends, good understanding of others perspectives, no challenging or self- stimulatory behaviors present. Normal range on all exit testing (IQ, language, TOM, EF)

59. A.D.: Challenging Behaviors per month

60. A.D.: New Skills per month

61. What do we learn from these Case Studies? A variety of medical interventions worked for these children Each child benefited from a different type of intervention Autism is a “Spectrum Disorder”…children with Autism are very different from each other! Not every intervention will work for every child….except for ABA!

62. What is Applied Behavior Analysis 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!

63. What does that mean? In ABA we change behavior by changing antecedents and consequences What is a behavior?  Behavior is anything we do What is an antecedent?  An Antecedent is whatever happened just before the behavior What is a consequence?  A Consequence is whatever happens just after the behavior

64. 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 Instruction Give rewards for these Behavior Management Remove rewards for these

65. Why does a child have challenging behaviors? Everything we do is to  Get a Reward  Avoid a Punishment Challenging Behavior is the child’s way of telling us what he wants He may not realize that his way of telling us is not the “appropriate way” He may not have the skills to tell us the appropriate way!

66. What is this child trying to get?

67. Positive things children want: Attention good or bad Tangibles our favorite foods fun activities toys playground

68. Negative things children avoid  Having to work  Classroom  Listening to people telling us what to do  Giving up something we want to keep doing  Sensory Overload  Getting ready in the morning

69. How do we change Behavior GiveRemove positive Behavior negative Behavior + Reinforcement - Reinforcement Response Cost Extinction Punishment

70. How do we change behavior? Change behavior by changing the antecedent or the consequence or both! Todd wants toy Todd hits sibling Todd gets toy Todd does not get toy Teach Todd to ask when he wants toy Todd will not hit sibling Mark wants attention Mark cries and tantrums Mark gets attention Mark doesn’t get attention Teach Mark to do something appropriate Mark does something appropriate Mark gets attention Jon hates school Jon screams Jon is sent home Jon is not sent home Jon learns skills so he likes school Jon will not scream

71. Step 1: Identifying what the child wants to communicate Step 2: Teaching the child more appropriate ways to communicate If we teach appropriate communication skills, they will replace challenging behaviors in our kids Challenging behaviors are NOT part of the Autism diagnosis! They are just a form of communication!

72. Summary Identify the behavior you want to change Identify why it is happening  What is your child trying to communicate?  What does he want to have or avoid? Now that you know the function, you can change the behavior How? By changing either the antecedent or the consequence…or both! The FUNCTION of the behavior tells you what to do!

73. Extinction for Tangible Function

74. Example of DRA

75. The Secret to successful ABA The key is to teach appropriate skills! If a child has appropriate skills, and they are easy to do, he will not engage in challenging behaviors! We cannot simply “extinguish” challenging behaviors without replacing them first, with appropriate skills!

76. We learned how to use ABA to change behavior Now lets look at how we can use ABA to teach skills Same principles

77. 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 Instruction Give rewards for these Behavior Management Remove rewards for these

78. The CARD Curriculum Language Adaptive Motor Academic PlayCognitive Executive Functions Social

79. The CARD Curriculum 0-11 mos. Body Parts Following Instructions Gestures Making Requests People Sound Discrimination Verbal Imitation Yes/No 1:0 – 1:11 yrs. Actions Asking for Information Categories Language Choices Fast Mapping Functions Objects Opposites Prepositions Pronouns 2:0-2:11 yrs. Adverbs Attribute- Object Conditionality Deliver a Message Features Gender I Have/ISee Listen to/Tell a Story Locations Negation Plurals Recalling Events Sound Speed & Duration Syllable Segmentation Wh- Discrimination 3:0-3:11 yrs. Minimal Pairs Same/Different Sequences Sound Changes Statement- Statement 4:0-4:11 yrs. Describe by Category/Feature/ Function Phonic Same/ Different Statement- Question What Goes With 5:0-5:11 yrs. Observational Learning Syntax By Emerging Age and Verbal Operant:

80. Mixed Operants

81. Play Curriculum Play Domains Electronic Play Beginning Play Interactive Play Pretend Play Constructive Play Sensorimotor Play Task Completion Play Initiating and Sustaining Play Early Social Games Read-to-Me Books & Nursery Rhymes Music and Movement Treasure Hunt Card and Board Games Locomotor Play Peer Play Functional Pretend Play Symbolic Play Imaginary Play Sociodramatic Play Block Imitation Structure Building Sand and Water Constructions Clay Constructions Arts and Crafts Audio and Video Play Computer Play Video Games

82. Interactive Play: Nursery Rhymes

83. Adaptive Curriculum Adaptive Domestic Pet Care Setting & Clearing Table Telephone Skills Tidying Meal Preparation Cleaning Gardening Laundry School Backpack Prep Making a Bed Safety Safety Awareness Safety Equipment Community Shopping Restaurant Readiness Personal Feeding Toileting Undressing Unfastening Dressing Preventing Spread of Germs Bathing Fastening Teeth Care Hair Care Nail Care Health Care

84. Motor Curriculum Motor Gross Fine Oral Visual

85. 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

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

87. 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

88. “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

89. Cognition Curriculum 13 Lessons Physical States Emotions Cause & Effect Senses Sensory Perspective Taking Desires Preferences Cognition

90. Understanding other perspectives

91. Social Skills Curriculum Social Skills Social Skills Non-Vocal Social Behavior Social Language Social Interaction Self Esteem Social Context Social Rules Group Related Skills Absurdities Group Related Skills Responding in Unison Group Discussion Non-Vocal Social Behavior Eye Contact Non-Vocal Imitation Body Language & Facial Expressions Gestures to Regulate Social Interaction Social Language Greetings and Salutations Social ID Questions Prosody Regulating Others Conversational Audience Physical Context of Conversation Listening to Conversation Initiating Conversation Joining Conversation Maintaining Conversation Repairing Conversation Transitioning Topics of Conversation Ending Conversation Social Interaction Apologizing Assertiveness Compliments Cooperation & Negotiation Gaining Attention Introductions Levels of Friendship Sharing & Turn Taking Lending & Borrowing Self Esteem Dealing with Conflict Positive Self-Statements Winning & Losing Constructive Criticism Social Context Responding to Social Cues Learning Through Observation Social Rules Compliance Following Rules Community Rules Politeness & Manners Absurdities Figures of Speech Humor and Jokes What’s Wrong?

92. Responding to Social Cues

93. 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?

94. Executive Functions Curriculum Executive Functions Planning Meta- Cognitive Planning InhibitionFlexibility Attention Memory EF Flexibility/ Set-Shifting Non-Social, Social, Social –Cognitive, Situational Attention Social Orienting, Joint Attention, Sustained, Divided, & Alternating Attention, Determining Saliency, Depth of Processing, Paraphrasing, Task Persistence Memory Associative, Visual, Spatial, Auditory, Episodic, Working Inhibition Waiting, Physical / Motor, Vocal, Pencil / Paper Problem Solving Problem Solving Non-Social, Social Planning Task / Social Goal Setting, Previewing, Task Initiation, Monitoring Progress, Time Management, Organizing Materials, Using a Planner, Self-Organization Meta-Cognition Meta-cognitive Planning, Self-Evaluation, Meta-memory, Self-Monitoring of Attention, Emotions, Reinforcement Control, Study Skills, & Flexibility

95. Children’s Color Trail Test

96. Stroop Activities

97. Problem Solving: clarification

98. Telling Jokes

99. Summary A good ABA program requires good assessment to determine exactly what your child needs to learn! A good ABA program needs a lot of hours! Don’t do 5 hours of ABA when 40 hours are recommended! This is like taking 5 mgs of a drug that has shown to be effective at 40 mgs! It wont work!

100. 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

101. 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)

102. 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

103. 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

104. Summary Treat each child differently Identify the medical issues that need treatment and treat them so that the child is medically stable, sleeping well and attending Identify the sensory deficits that may be prohibiting normal learning so that you can modify the way you teach Use ABA techniques to teach the child all the things he is lacking