autism spectrum disorders - kids...

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Autism Spectrum DisordersScience, Strategies, Success

Brenda Alred, M.S., CCC-SLP

Kimberly Norris, M.Ed.


Outline for Today

• Autism – The Science

– What is autism?

– What do the criteria mean for development and learning?

• Strategies for Success

– Visual Strategies

– Social Narratives

– Behavioral Interventions

– Pivotal Response Training


Developmental Domains

Social Receptive Language

Expressive Language

Fine Motor

Gross Motor

Adaptive Cognitive


Developmental Milestones:Integration

Example:

Asymmetrical Tonic Neck

Reflex

~2 months of age

Disappears by 4 months

Why?


Example

• 3 year old(typical development)

– Basic concept of time

– Separates easily from parents

– May give up comfort objects

– Independently perform daily tasks

Upset by changes in routine


Autism

https://www.youtube.com/watch?v

=Lr4_dOorquQ

Can you make it to the end.mp4

https://www.youtube.com/watch?v=Lr4_dOorquQ


Neurodevelopmental Disorder

Neuro Developmental Disorder


Autism Spectrum Disorder

• Neurodevelopmental DisorderA. Social Communication Deficits

1. Social-emotional reciprocity

2. Non-verbal communication

3. Relationships

B. Repetitive, Restricted Behavior & Interests

1. Repetitive movements or speech

2. Rigidity / Inflexibilty

3. Restricted interests

4. Sensory processing differences


Social Communication

All communication is social…

but some is more social than others

•What is communication?

•How do we communicate?

– Verbally

– Non-verbally


Social Communication &Functional Language

• How many words does the child have?

• Can the child– Label things?

– Request items?

– Ask questions?

– Comment?

– Go back and forth in conversation?

– Navigate conflicts verbally?


Social Communication & Non-Verbal Compensation

• Intentional, Purposeful– Specific Gestures

• Single finger point

• “integrated”

– Facial Expressions

– Eye contact• Gaze tracking

– Communication systems• PECS, signing, talkers

• Written language!


Developmental Domains

Social

Receptive Language

Expressive Language

Fine Motor

Gross Motor

AdaptiveCognitive


Intelligence

• “Smart”– Cognitive Development

– Problem solving or thinking skills

• Street smart– Functional intelligence

– Adaptive Skillsctional skills

• Showing your smarts– IQ tests

– Developmental assessments

Cognitive


Cognition & ASD

Let’s do an IQ test:

Question 1: Words, words, words, words… - how does a person with weak verbal skills process all those WORDS?


Example: Visual vs. Verbal

• Visual skills

• Visual intelligence…

• Verbal skills

• Verbal intelligence…


Thinking in Pictures

• Intelligence

– Visual-spatial

– Verbal


ASD & “Scatter Skills”

• Hyperlexia: Sounding out words vs. reading comprehension

• Visual vs. Verbal intelligence

• Long-term vs. short-term memory


Developmental Delay

IS

NOT

Developmental

Arrest


Visual Strategies


What are Visual Supports?

• Photographs

• Drawings

• Objects

• Written Words

• Schedules - Lists


Common Visual Supports


• Maps

• Charts

• Calendars

• Watches

• To-do lists

• Organizational Apps

• Body language

• Road signs

Adults Use Visual Supports All the Time!


Why Do Children with ASD need Visual Supports?

• Decreases anxiety

• Decreases meltdowns due to anxiety/fear

• Increases compliance

• Increases ability to follow directions

• Increases self reliance/independence

• Increases communication


Why Visual Strategies for Children with ASD?

• Visual processors- The visual support utilizes the part of the brain

that is more developed in children with ASD.

• Slow language processors- (may take 30 – 60 seconds to

process auditory stimuli)

• Anxious- Decrease anxiety because they don’t have to stress about

trying to figure out what is being asked of them

• Decreases Meltdowns -Decreases episodes of child acting out

due to frustration


Simple Drawings


Single Pictures

http://csefel.vanderbilt.edu/resources/modules-archive.html

Module 3b (Archive) video clips

Video Name: “New Skill: Transition to Breakfast”

http://csefel.vanderbilt.edu/resources/modules-archive.html


Stop


No / Wait / Not Now


First and Then

ThenFirst


First and Then

First Then

• Start teaching using 2 preferred items


First and Then

First Then


Follow Directions

First Then


Timers are your Friend

• Transitioning

• Staying on Task

• Tolerating Unpreferred Activities

• Promoting Independence

• Excert from Brenda Kosky Deskin, editor of AutismBeacon.com


Timers


Visuals in Circle Time

• USE THEM!

• Plan in advance- have pictures of items from story/book/song

• Have a notebook or folder for circle time


Circle Time – Visual Support Book


Taking Pictures

Incorrect Correct


Making Pictures 101

• Search google – copy and paste into template

• Use “insert” function – online pictures Word

• Pintrest

• Boardmaker

• Mrs Riley

• Templates- use label function Word


Finished


Relationships

• Early learning is nearly always SOCIAL


• Affective Reciprocity – I smile you smile

– Early infancy

• Joint Attention– Look, Mom! A plane!

– 9-18 months

• Intuitive Psychology – Walk in your shoes

– 4-5 years and up

Social Development


Pivotal Skills in Social Development

• Joint attention

• Imitation

• Reciprocal engagement


Joint Attention

• First year of life

• Coordinate attention

• 2 categories: Responding and Initiating


Joint attention – CDC autism video

https://www.youtube.com/watch?v=1Q2CzTJh7nI

https://www.youtube.com/watch?v=1Q2CzTJh7nI


Imitation

• Parents/teachers

• Peers (social learning)


Reciprocal Engagement

• Paying attention to PEOPLE vs. things

• “Back and forth”

• For long enough to

– learn something

– enjoy something

– share something


• Affective Reciprocity – I smile you smile

– Early infancy

• Joint Attention– Look, Mom! A plane!

– 9-18 months

• Theory of Mind – You’re not me

– 18-30 months

• Intuitive Psychology – Walk in your shoes

– 4-5 years and up

Social Development


Before Theory of Mind has formed

Source: http://www.hanen.org/Helpful-Info/Articles/Tuning-In-to-Others-How-Young-Children-Develop.aspx


Me, Myself & I(Me, My Mom & My ice-cream)


1. As social as his IQ would predict

2. As social as he needs to be in his world, right now

What do we mean by “deficit”?

“Just how social do you need him to be?”


Social Deficit?

Soci

al

Lan

guag

eCo

gnit

ive

(IQ

)


Social Deficit?

Soci

al

Lan

guag

e

Co

gnit

ive

(IQ

)


Social Deficit?

• 5 year old boy

• Only talks about trains

• Poor eye contact

• Poor understanding of other’s feelings

• Expectation of perfection in self & others

• Low tolerance for changes in routine

• Can’t stand to be touched

• Sometimes aggressive when frustrated


Social Narratives


Volunteering at NAEYC Conference Social Narrative


Some people think this is exciting!Others might get nervous.


The activity is all finished.


What is a social narrative?

• “learning tool that supports the safe and meaningful exchange of information between parents, professionals, and people with autism of all ages. “ - Carol Gray

• Brief, simple story that is created to show your child what to expect, and what is expected of him, during a specific activity.

• Social Narratives present appropriate social behaviors in the form of a story.


Social Narratives can be used to:

• Teach social skills - such as how to take turns.

• Reinforce routines - such as washing hands.

• Prepare for new experiences- such as holidays, community week, young athletes day, fire drills, or the first day of school.

• Address a challenging behavior - such as hitting or biting.


Why do we want to use Social Narratives?

• Evidenced based.

• Decreases anxiety. They know what to expect.

• Often our kids have language delays and they may not understand what you are saying.

• Auditory processing may be delayed.


Carol Gray

Social Stories TM

vs.

social stories

(or social narratives)


Let’s read a few social narratives.


You could end the story here. Or….

What kind of affirmative sentences could

you add at the end?

Think about it and we can come back to

this story.


How do I write a social narrative?

Identify the need for the story.


Developing the story with basic sentences

There are 4 basic sentence types:

• Descriptive

• Perspective

• Directive

• Affirmative


Descriptive Sentences

• The only required type of sentence in a social narrative and the most frequently used.

• Descriptive sentences form the backbone to a social narrative.

• They often answer important “wh” questions that guide the story development.


Examples Descriptive Sentences

• My name is _________.

• Sometimes, my grandmother reads to me.

• Many children play on the playground during outdoor recess.


Perspective Sentences

• Perspective sentences are statements that refer to, or describe, a person’s internal state, their knowledge/thoughts, feelings, beliefs, opinions, motivation, or physical condition/health.

• These rarely describe the person with ASD.

• They frequently describe the internal status of OTHER people.


Example Perspective Sentences

1)My teacher knows about math.

2)My sister usually likes to play the piano.

3)Some children believe Unicorns are real.

4)Many children like peanut butter and jelly sandwiches for lunch.


Directive Sentences

• These sentences identify a suggested response.

• Authors must carefully develop these sentences, paying special attention to the possibility of literal interpretation.


Examples Directive Sentences

• I will try to stay in my chair.

• I may ask Mom or Dad for a hug.

• On the playground, I may decide to play on the swings, or on the monkey bars.


Affirmative Sentences

• Usually affirmative sentences immediately follow a descriptive, perspective or directive sentence.


Examples of Affirmative Sentences(in red)

1)Most people eat dinner before dessert. This is a good idea.

2)I will try to keep my seat belt fastened. This is very important.

3)One child slides down the water slide at a time. This is a safe thing to do.

4)The toilet makes a sound when it flushes. This is okay.


Ratio rule of thumb1:2-5

1 directive sentence

plus

2- 5 supporting sentences(descriptive, perspective and/or affirmative).


.

In other words…

you don’t want a social narrative looking like a rule

book from a sergeant.

It should be a story and describe what’s going on


I will go to the sink.

I will turn on the water.

I will put soap on my hands.

I will turn off the water.

I will dry my hands.

All directive sentences.


It’s good to keep my hands clean, especially before I eat.

Keeping my hands clean will help me stay healthy.

I wash my hands at the sink. I turn the facet on for the water to

come on.

The soap is usually right beside the sink. I will use soap on my

hands and rub my hands together.

Next, I rinse off the soap under the water and then turn off the water.

My hands are wet, so I will need to dry them with a paper towel. I

am all finished now. I did it!


Use first person point of view in the story.


Use

pictures.


Watch out for pictures that are too busy and cluttered.


Autism Spectrum Disorder

• Neurodevelopmental DisorderA. Social Communication Deficits

1. Social-emotional reciprocity

2. Non-verbal communication

3. Relationships

B. Repetitive, Restricted Behavior & Interests

1. Repetitive movements or speech

2. Rigidity / Inflexibilty

3. Restricted interests

4. Sensory processing differences


Repetitive Movements or Speech


Rigidity / Inflexibility

• Sameness

• Routines

• Ritualized behavior


Restricted Interests or Activities


Sensory Processing Differences

• Hypersensitive

• Hyposensitive

• Unusual interest in sensory input


Arousal States

7:00 a.m. 10:00 a.m. 1:00 p.m. 5:00 p.m.


7:00 a.m. 10:00 a.m. 1:00 p.m. 5:00 p.m.

Arousal States


Observing Arousal State


Outline for Today

• Autism – The Science

– What is autism?

– What do the criteria mean for development and learning?

• Strategies for Success

– Pivotal Response Training

– Visual Strategies

– Social Narratives

– Antecedent Based Intervention


Behavior “Maps” onto Development

• Behavior is the observable evidence of a person’s skill set

Behavior

Skills


Behavior & Development

• The “Hot Spots”


Transitions

• Object permanence

• Sense of Time

• Sensory processing

• Attention span

• Self-regulation


Compliance

• Receptive Language

• Joint attention

• Short term memory

• Cause-effect


Classroom Participation

• Receptive Language

• Joint attention

• Short-term memory

• Cause-effect

• Reciprocal engagement with peers

• Sensory processing

• Sense of time


Self-Regulation

• Control over

– Emotions

– Thoughts

– Behavior


Behavioral Interventions


Skills and Behavior

What’s more important:

What you know?

What you do?

Can you USE the skills?

Are they FUNCTIONAL?

Behavior

Skills


Teaching Behavior

• Break skills into small, observable, behaviors (functional skills)

• Teaching behavior = changing behavior

• How do we change behavior?


Ante = beforeContext / SettingTrigger / Prompt

Antecedent

The ABCs of Behavior Change

Defined specificallyDescribed accurately

What happens next?How is it “working” for the kid?How well does it “work”?

Behavior

Consequence


What is Behavior?

• Anything (& everything) that we do

– Hitting

– Raising your hand for help

– Washing hands independently

– Pointing to colors when asked

– Blending sounds correctly

– Making eye contact

– Standing on one foot for 5 seconds


Antecedent Behavior Consequence

JOHNNY

ABCs of Behavior


What to Teach

SKILLS = BEHAVIOR

- Functional

- Discrete


Functional

• What does it mean if a goal is functional?

• Def: “designed to have a practical use”

• Practical Meaningful, helpful, appropriate

• Use Active (“doing” not “knowing”)


Example:

Functional Communication Goals

Does the child….Label things?

Request things?

Ask for help? (Request information or assistance?)

Ask questions? (Who? What? When? Where?)

Comment on things?

Greet people appropriately?

Maintain reciprocal conversation?


What to Teach: Functional Goals

Ex: “stand on one foot”

Functional?• Active?

– Yes!

• Meaningful?– Maybe not by itself

– Maybe as art of a larger, more meaningful goal



Goal: Put on pants independently

Objectives:- Identify “front” & “back” of pants

- Hold pants ”open” in front of waist

- Stand on one leg

- Put one leg then the other into the pants

- Pull pants up

Overarching

Functional

(Meaningful,

Active) Goal

Discrete

(small)

steps

towards

that goal



Ex: “Know Colors”

Functional?• Meaningful?

– Requesting, commenting, drawing attention to things

– Basis of play/interactions with adults & peers

• Active? – How do I know a child “knows” colors?

– Phrased as an active, observable behavior?

How could we re-write it? “Identify Colors”


What to Teach: Functional, Discrete Goals & Objectives

Example: Identify Colors

Behavior Identifies the color red

Developmental Skills Social (Joint attention)

Receptive language (“where’s red?”)

Fine motor (point)

Cognitive (colors)

“identify”

“red”


Group Activity

Rewrite this objective to be discrete and functional:

“Johnny will know his colors.”

“Johnny will identify a red crayon.”


Where’s Red?


What do I count?

• When presented with 3 crayons spread on the table, when Ms. Kimberly says “where’s red?”, Johnny will identify the red crayon.


If you can count it, you can teach it.

• When presented with 3 crayons spread on the table, when Ms. Kimberly says “where’s red?”, Johnny will identify the red crayon by picking it up, touching or pointing to it.


Pop Quiz

What do we teach Johnny next?

A. Whatever skill “comes next” in our curriculum

B. Whatever the other kids in the class are doing

C. Whatever we know how to teach

D. Whatever he needs most, right now, to be more successful & independent across settings



ABCs of Behavior

Environment

Leading

Prompting

“The Set Up”

When sitting at the

classroom table with 3

crayons spread on the

table, when Ms. Kimberly

says “where’s red?”,

Johnny will pick up or

point to the red crayon.


Changing Behavior

Control the Environment:Positive Behavior Supports


Control the Environment

“Environment” ?

- Physical environment

- Emotional environment: Self-Regulation

- Skill set, “toolkit”

David1.wmv


Site Group Activity

• Brainstorm positive behavior supports

– Strategies to prevent unwanted behavior, encourage desired behavior, etc.

• Which category do they fall in?

– Physical Environment

– Emotional/Sensory Regulation

– Skill set


Positive Behavior Supports

• Strategies to Control the Physical Environment– Access to toys and materials

– Access to teacher materials

– Furniture arrangement

– Visual schedules

– What else?

Own the Room



• Strategies for Emotional/Sensory Regulation

– Sensory Environment• Lights, sounds, visual stimuli

• Calming/soothing vs. activating/engaging

– Anticipation & Anxiety• Routine, “count downs”

• Transition objects, picture schedules

– Emotional Supports• Caregivers’ emotions

• REACH Training, infant mental health



• Strategies to increase Behavior skill sets

– Awareness of child’s skill level

– Awareness of skills required for a behavior

Ex: - Sitting in a chair for 5 seconds, 10 seconds, 30 seconds

- Asking for help

- Functional communication system (PECS, signs, etc.)

- Counting to 10, walking away, deep breaths, etc.


A: Environment

When presented with 3 crayons spread on the table, when Ms. Kimberly says “where’s red?”, Johnny will identify the red crayon by picking it up or pointing to it.


A: Lead Them To It

When presented with 3 crayons spread on the

table, when Ms. Kimberly says “where’s red?”,

Johnny will identify the red crayon by picking it

up or pointing to it.


A: Prompting

• Different kinds of prompts:

– Gestural (pointing to the red one)

– Model (demonstrate action)

– Facial Expression (smiling, etc.)

– Intentional & Unintentional

Making a Plan for Prompts

- How? When? How often?

- “Fading” prompts so they do it on their own



ABCs of Behavior

Environment

Leading

Prompting

“The Set Up”

When sitting at the

classroom table with 3

crayons spread on the

table, when Ms. Kimberly

says “where’s red?”,

Johnny will pick up or

point to the red crayon.

The Result

Make it

worth their

while!


Reinforcement

What will make them do the behavior again?

Give them “good stuff”

Take away “bad stuff”


Reinforcement = Motivation

People are sort of complicated…

• Some people don’t like cupcakes.

• Some people really do like doing dishes.

• Some people don’t like cupcakes ENOUGH to make them do the dishes.

Don’t Assume. Observe.


Reinforcers

• Motivating– From the kids’ point of view

– Changes with the task & over time

• Easily accessible– Immediate

• Not otherwise available– Satiation

• Natural (when possible)– Related to the behavior they just did


Pivotal Response Training


Ante = beforeContext / SettingTrigger / Prompt

Antecedent

The ABCs of Behavior Change

Defined specificallyDescribed accurately

What happens next?How is it “working” for the kid?How well does it “work”?

Behavior

Consequence


Dr. Koegel, founder/developer of PRT was featured on Supernanny!

https://www.youtube.com/watch?v=oYQ0R6pSFGE -`

-

https://www.youtube.com/watch?v=oYQ0R6pSFGE


What About Mom

• How do you think she felt in the beginning?

• What about after her child spoke?

• You will be like the mom.

• If the mom could do YOU can do it too!


Pivotal Response Treatment (PRT)

• Primary purpose to initiate speech

• Evidenced based

• Derived from ABA

• Play based and child initiated


The goals of PRT are to:

• Develop communication and language

• Develop positive social behaviors

• Develop relief from disruptive self-stim behaviors


EVERYWHERE and

ANYWHERE!!

OutsidePlay-

ground

Classroom

Kitchen

Bedtime

Meals

With friends

At the

pool

Family Room

In the Car

Where does PRT happen?


First Things First

Because a child with autism most likely has:

• Poor social skills

• Selective / unusual interests

• Poor Communication Skills - Often non-verbal before age 5

• Sensory/ Self-Regulation Issues

You have to figure out what will motivate them to interact with you!


Is the key to success!

• What Motivates You?


#1 - Motivation should be child choice!!


How do I identify the motivator?


Reinforcers/ Motivators

• This is one of the most powerful tools you can have in your tool kit.

• Simply put- reinforcers are something the child has demonstrated in the past they have a strong interest in.

• Use a checklist of some type for parents to complete, that lists the various objects, toys, games, videos, food, etc.

• Many free ones available under ABA Reinforcer Assessments


Reinforcers/Motivators

Should contain a variety of topics such as:

1. Social and Sensory Reinforcers

• Hugs

• Adult attention

• Time with peers

• Being left alone

• Swinging

• Vibrations

• Stim time

• Tickles


Reinforcers/Motivators (cont.)

2. Activity Reinforcers

– Music- types

– Toys – list

– Puzzles

– Outside play

– Books / Being read to

– Water play

– Bubbles

– Other



3. Areas of Interest– Computers – list out programs– Favorite TV shows – Favorite Movies – Favorite Songs– Favorite Color – Cars/trucks – Weather– Trains – Dinosaurs– Numbers– Shapes



4. Dislikes

– Foods

– Drinks

– Noises

– Activities

– Animals

– Any other fears or dislikes



5. Preferred tangible items by product/name

– Chips - _________________________

– Cookies - _______________________

– Candy - ________________________

– Cereal - ________________________

– Toy - __________________________

– Snacks - _______________________

– Games - _______________________

– Other - ________________________


#2 - Motivation should be a Natural Reinforcement in the Natural Environment!!!


#3 – Natural vs. Unnatural (Artificial) Reinforcers

Unnatural (Artificial)• Don’t have anything to do with the behavior (sticker,

candy)• May not always be around• Eventually lose their power

Natural Reinforcers

• Make sense in the context of the behavior

• Natural Consequences

• Work better for long term behavior

change


Unnatural example:


The ABC’s of PRT!


A Antecedent

a thing or event that existed before or logically precedes another.

B Behavior

the way in which a person acts in response to a particular situation or stimulus

C Consequence

a result or effect of an action or condition.

Antecedent: parent models the word “doll”

Behavior: child says the sound “da” Consequence: parent hands the doll to the child

Parent models the word “bubble” Child says “BUB-B” Parent blows a bubble

Parent has a cookie in hand and prompts the word “cookie”

Child says “cookie” Parent gives child cookie


Basic PRT + Social ResponseAntecedent Behavior Consequence Embedded Social R+

Consequence

Bouncing on a Trampoline, Child prompted to say “jump”

Child says “jump” Child is given opportunity to jump on the trampoline

Parent jumps with the child

Listening to a preferred song on TV, Child is prompted to say “music”

Child requests “music” Parent starts the video and allows the child to hear the preferred song

Parent sings the preferredsong to the child

Playing on a swing, child is prompted to request “swing”.

Child request “swing” Child is given the opportunity to play on the swing

Parent pushes the child on the swing

Playing in bathtub, child is prompted to request “splash”.

Child requests “splash” Child is given the opportunity to splash around

Parent splashes with the child

Playing with a blanket, child is prompted to request “blanket”

Child request “blanket” Child is given preferred blanket

Parent plays peek –a- boo with child.


Evidence-Based Practices

National Standards Project

Discrete trial training

Pivotal response training

Modeling Strategies

Behavioral Interventions

Social Skills Strategies

Visual strategies

Social narratives

+ more…

www.nationalautismcenter.org


Questions

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