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Behavioral Approaches to Early Intervention with Autism. WAYNE W. FISHER Munroe-Meyer Institute at the University of Nebraska Medical Center. Autism and Childhood Schizophrenia. Once thought to be a form of schizophrenia

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Behavioral approaches to early intervention with autism l.jpg

Behavioral Approaches to Early Intervention with Autism

WAYNE W. FISHER

Munroe-Meyer Institute at the

University of Nebraska Medical Center


Autism and childhood schizophrenia l.jpg
Autism and Childhood Schizophrenia

  • Once thought to be a form of schizophrenia

  • Differs from schizophrenia in terms of symptoms, age of onset, family history, etiology, and response to treatment


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Definition of Autism

  • markedly abnormal or impaireddevelopment in:

    • social interaction

    • communication

  • and markedly restricted repertoire of activities and interests.


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Definition of Autism (continued)

  • Definitions are cheap, but explanations are dear, and we must be careful not to confuse them.

    • David Palmer, 2004


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Autism Spectrum Disorders

  • Neurological disorders characterized by "severe and pervasive impairment in several areas of development

    • Autistic Disorder

    • Asperger's Disorder

    • Childhood Disintegrative Disorder (CDD)

    • Rett's Disorder

    • PDD-Not Otherwise Specified (PDD-NOS)


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Prevalence of Autism

  • Typically diagnosed within first three years

  • 2 to 6 in 1,000 individuals (Centers for Disease Control and Prevention, 2001)

  • Four times more prevalent in boys than girls


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NIH Research Dollars Devoted to Autism

  • When compared with other serious childhood conditions, autism is much more common, but fewer dollars per case are spent on autism.


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Prevalence of Autism and Other Conditions

(Number of Cases per 10,000 Children)

70

60

50

40

30

20

10

0

Autism

Juvenile Diabetes

Muscular Dystrophy

Leukemia

Cystic Fibrosis


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NIH Research Dollars for Autism and Other Conditions

(Number of Dollars per Case)

$140,000

$120,000

$100,000

$80,000

$60,000

$40,000

$20,000

$-

Autism

Juvenile Diabetes

Muscular Dystrophy

Leukemia

Cystic Fibrosis


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Demographics of Autism

  • Knows no racial, ethnic, or social boundaries

  • Family income, lifestyle, and educational levels do not affect the chance of autism's occurrence

  • Diagnosis of autism is growing at a rate of

    10-17% per year (U.S. Department of Education, 2002)


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Assessment and Diagnosis of Autism

  • No medical tests for diagnosing autism

  • Accurate diagnosis is based on observation of the individual's communication, behavior, and developmental levels.

    • Autism Diagnostic Interview-R (ADI-R)

    • Home and/or school observation

    • Video analysis of behavioral observation


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Identifying the Genetic Bases of Autism Spectrum Disorders

  • Etiologic workups identify specific genetic causes for autism in about 20% of cases.

  • At the Munroe-Meyer Institute, Dr. Schaefer and colleagues (2006) developed a 3-Tiered Approach that identifies genetic causes in 40% of cases.


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Early Screening for Autism (NICHD)

  • Does not babble or coo by 12 months

  • Does not gesture (point, wave, grasp) by 12 months

  • Does not say single words by 16 months

  • Does not say two-word phrases on his or her own by 24 months

  • Has any loss of any language or social skill at any age


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Early Screening for Autism (CHAT)

  • Does not display pretend play (e.g., pretending to drink from a toy cup)

  • Does not point at objects to indicate interest

  • Does not show interest in other children

  • Does not enjoy peek-a-boo hide-and-seek or other social games

  • Does not bring and show objects to parents


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Associated Disorders

  • Mental Retardation 70% 15%

  • Seizure Disorder 35% 10%

  • Self-Injury, Aggression 50%

  • Tourette Disorder

  • Bipolar Disorder

Autism ASD


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Associated Etiologic Diagnoses

  • Fragile-X syndrome

  • Tuberous Sclerosis

  • Williams syndrome

  • Landau-Kleffner syndrome

  • Congenital Rubella

  • Smith-Magenis syndrome

  • Neurofibromatosis


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Genetics and Twin Studies

  • Autism runs in families

  • Heritability for autism is about 90%

  • Monozygotic twin concordance, 60%-100%

  • Dizygotic twin concordance, 10%

  • Associated with abnormalities on chromosomes 7q, 2q, and 15q


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Applied Behavior Analysis (ABA)

  • What is ABA?

  • How is it different from other approaches?

  • How is it done?


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Baer, Wolf, & Risley (1968)

APPLIED—strives to produce rapid and clear benefit to problems of social importance;

BEHAVIORAL—usesobjective and accurate measurement of the behavior of interest;

ANALYSIS—uses controlled (single-case) methods to understand the environmental variable(s) that influence an individual’s behavior.


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Historical Roots of Behavior Analysis

  • 1911 Thorndike-Law of effect

  • 1924 Watson-Behaviorism

  • 1927 Pavlov-Conditioned Reflexes

  • 1938-Skinner Behavior of Organisms

  • 1950’s-Behavioral applications reported in scientific journals

  • 1968-Journal of Applied Behavior Analysis


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How Effective is ABA for Autism?

  • About 50% of Children with autism and mild mental retardation who received early intervention with ABA attain normal IQs and are educated in regular classrooms with minimal assistance.


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Outcomes of ABA for Autism

35

30

25

20

Increases in IQ Scores

r = .79

15

p < .02

10

5

0

0

5

10

15

20

25

30

35

40

45

Hours per Week of Treatment


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How Effective is ABA for Autism?

  • Early Intervention of Autism using ABA has been recommended by:

    • New York State Dept. of Health

    • U.S. Surgeon General

    • National Research Council

    • Association for Science in Autism Treatment


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Why is ABA Effective?

  • ABA developed from and remains closely linked to basic research on the principles of learning and behavior.

  • A central principle of ABA is called “Selection by Consequences.”

    • In a given environment, behaviors that produce favorable outcomes are selected (or continue to occur) and those that produce unfavorable consequences are extinguished.


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Why is ABA Effective? (continued)

  • ABA has developed a wide variety of procedures for identifying the antecedents and consequences that influence behavior.

  • We rearrange the antecedents and consequences in the environment so that appropriate behavior is selected (or re-occurs) and problem behavior is extinguished.


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Why is ABA Effective? (continued)

  • Specific procedures include

    • Shaping

    • Chaining

    • Prompting

    • Fading

    • Extinction

    • Reinforcement

    • Generalization strategies, etc.


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Why is ABA Effective with Autism?

  • Comprehensive: Teaches all skills (e.g., sitting, attending, imitating, direction following, language, social skills, self-help skills).

  • Goal and Data Driven: The focus on objective measurement and analysis of behavior provides ongoing feedback on progress and setbacks.


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Example of Individual Goals for Billy

  • Decease self-injurious behavior

  • Increase eye contact

  • Increase spontaneous requesting

  • Increase labeling skills

  • Increase use of yes and no

  • Increase imitation skills

  • Increase matching skills

  • Increase letter identification

  • Increase self-feeding skills


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Teaching Imitation Using Discrete Trials

  • Starts with simple responses (e.g., clapping).

  • Sessions consisting of 10 trials; each trial starts with the therapist saying “Do this” and then modeling the target response.

  • Any approximation of clapping, results in delivery of a preferred reinforcer (e.g., toy).

  • Otherwise, the therapist guides the child’s hands to complete the response and then begins the next trial.


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Teaching Imitation Using Discrete Trials (continued)

  • Once the first response is mastered, the same procedure would be used to teach a second response (e.g., waving).

  • After two responses are mastered in individual sessions, they would alternately be presented in the same session (e.g., “Do this” [clapping]; “Do this” [waving]).

  • Over time, additional responses are added until the child immediately imitates any new action the therapist does following the prompt, “Do this.”


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Generalization of Skills

  • Skills taught during discrete trials are then generalized to natural settings.

    • e.g., Clapping when another child answers correctly during group instruction or at a recital or school assembly.

    • e.g., Waving to another person when entering or leaving a room.


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100

Baseline

Differential Reinforcement + Feedback

90

80

70

60

PERCENTAGE CORRECT (TOTAL)

50

40

30

20

10

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

SESSIONS

Billy: Imitating a Model


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Why is ABA Effective with Autism? (continued)

  • Empirical Emphasis: Treatments are based on principles and procedures supported by research.

  • Intensity Level: 25 to 40 hours per week for 3 years.


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Early Behavioral Intervention for Autism

  • Lovaas, 1987; McEachin et al., 1993; Smith et al., 2000

  • Year 1--reduce aberrant behavior, teach attending, imitation, instruction following, speaking in short phrases, play skills, and self-help skills


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Early Behavioral Intervention for Autism (continued)

  • Year 2--extend expressive vocabulary, more abstract concepts, extend treatment to group and community settings

  • Year 3--pre-academic and academic skills, appropriate emotional expression, observational learning, and interactions and friendships with normally developing peers


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Cost-Benefit Analysis of Early, Intensive ABA for Autism

  • Average lifetime cost for a person with autism is over $4 million

  • Average cost of Early, Intensive ABA is $150,000 over about 3 years

  • Average lifetime savings from ABA Treatment is between $1.6 and $2.7 million


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Assessing Children with Autism

  • Periodic assessment for diagnosis and management

  • Ongoing assessment for intervention


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Periodic Assessment for Diagnosis and Management

  • Identify the child’s overall strengths and limitations

  • Determine the appropriate diagnosis or diagnoses

  • Set the global goals for treatment


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Components of a Diagnostic Assessment

  • Genetic/Etiologic workup

  • Assessment of behavior/symptoms

  • Formal audiologic evaluation

  • Cognitive testing

  • Assessment of adaptive behavior

  • Speech/Language evaluation


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Ongoing Assessment for Intervention

  • Identify the specific behaviors to be increased

  • Identify the specific behaviors to be decreased

  • Identify effective reinforcers


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Assessment of Skills to Increase

  • Attending Skills

  • Compliance

  • Following Simple Instructions

  • Motor Imitation

  • Vocal Imitation

  • Matching

  • Play Skills

  • Social Skills

  • Self-Help Skills


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Skill Assessment Areas

  • Imitating Behavioral Chains

  • Following Multi-Step Instructions

  • Categorization

  • Verbal Behavior-Listener Skills

  • Verbal Behavior-Speaker Skills

  • Pre-academic and Academic Skills


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Matching Skills Progression

  • Identity matching with objects

  • Identity matching with pictures

  • Matching pictures to objects

  • Matching objects to pictures

  • Matching shapes, colors, letters, numbers

  • Matching on 2 dimensions (color-shape)

  • Matching by categories (e.g., animals, vehicles)

  • Matching objects with their spoken names

  • Matching pictures with their spoken names


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Social Skills Progression

  • Shaking hands

  • Making eye contact during greetings

  • Imitating a smile

  • Smiling reciprocally

  • Appropriately getting someone’s attention

  • Appropriately exchanging toys with a peer

  • Playing a simple interactive game (roll ball)

  • Showing appropriate affection (e.g., hugs)

  • Taking turns during a simple game

  • Making polite statements (e.g., “Bless you. “Your welcome.”)

  • Initiating a conversation (e.g., “Did you watch the Huskers game?”)


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Preference Assessments

  • Children with developmental disabilities sometimes are not able to tell you what things they like or tell you when they want one thing instead of another.

  • Researchers have developed preference assessments to identify what things people with disabilities like.


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Steps of Preference Assessments

Step 1: Interview the parent with the RAISD to list the kinds of things that the child likes

Step 2: Get the actual items the parent nominated as highly preferred

Step 3: Allow the child to select items from the group

Step 4: Rank the items from high to low based on what the child chose


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Types of Preference Assessments

  • Single-item type – Present each item from the group one at a time

  • Choice type – Present all items 2 at a time and let the child choose between the 2.

  • Group type – Present all items together and let the child select items from the group


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Single-item Preference Assessments

  • Developed by Pace et al. (1985)

    • 16 stimuli

    • Each stimulus presented individually 10 times for 5 seconds each

      • The SI method identified highly preferred stimuli for all participants in the study

      • However, subsequent research has shown that the SI method may also yield a high number of false positives


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100

90

80

70

60

Percentage of trials chosen

50

40

30

20

10

0

Toy

Telephone

Barney

Doll

Action

Figures

Radio

Ball

Items


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Paired-Choice Preference Assessment

  • Developed by Fisher et al. (1992, 1996)

    • Take 5-10 top stimuli from the RAISD

    • Each stimulus paired once with every other stimulus

    • Two stimuli presented concurrently; the participant was prompted to choose one

      • The participants had to emit a choice


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100

90

80

70

60

50

40

30

20

10

0

Toy

Telephone

Barney

Doll

Action

Figures

Radio

Ball

Percentage of trials chosen

Items


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Group Preference Assessment- MSWO

  • Multiple Stimulus without replacement (MSWO) developed by DeLeon and Iwata (1996)

    • Compared three different preference assessments (PC method, MSWR, & MSWO)

    • Results obtained from MSWO were comparable to that obtained by the PC method


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100

90

80

70

60

Percentage of trials chosen

50

40

30

20

10

0

Toy

Telephone

Barney

Doll

Action

Figures

Radio

Ball

Items


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Preference Assessment Outcome

  • Items that the child chooses are usually the most effective positive reinforcer.


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Ongoing Preference Assessments

  • Paired-choice assessment conducted once every 4-6 months

  • Mini-MSWO assessments conducted daily or more frequently


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Compliance and Cooperation Training

  • Individuals on the autism spectrum often display problem behaviors in a variety of contexts including:

    • when instructional requests are presented

    • when asked to surrender an unusual object (e.g., piece of dirt) they are holding during instructions


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Compliance and Cooperation Training(continued)

  • Teaching a child to accept removal of a preferred object using delay fading.

  • Teaching compliance using least-to-most prompts.


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Teaching Tolerance for Instructional Task

  • The traditional approach to treating these problems involves extinction

  • Extinction often produces deprivation from reinforcement, which in turn, may evoke bursts of problem behavior


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Teaching Tolerance for Instructional Task(continued)

  • Bouxsein and Fisher (in press) evaluated an alternative to extinction.

  • The alternative involved the provision of a choice between surrendering the preferred object or completing the instructional tasks while retaining the object.


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Choice

100

3-Step

Prompting

w/ Extinction

3-Step

Prompting

w/ Extinction

Baseline

Choice

80

60

Percentage of Trials with Compliance

40

20

0

1

3

5

7

9

29

11

13

15

17

19

21

23

25

27

31

33

Session


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Baseline

3-Step

Choice

3-Step

Choice

100

80

60

Percentage of Intervals of Aggression and Disruption

40

20

0

1

3

5

6

8

10

11

13

15

17

19

21

22

24

26

28

31

33

Session


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Baseline

3-Step

Choice

3-Step

Choice

100

Task Choice

80

60

Percentage of Intervals of Choice Allocation

Item Choice

40

20

0

1

3

5

7

9

11

13

15

17

19

21

23

25

27

29

31

33

Session


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Compliance Training

  • This case illustrates a simple and effective way to increase compliance while decreasing problem behavior associated with presentation of instructions

  • This may be a result of decreasing the aversiveness of the instruction by allowing the child to choose whether to surrender a object or complete an alternative demand


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Improving Vocabulary Skills in Children with Autism

  • Recent behavior analytic work in autism has focused on teaching critical skills, ones that facilitate the acquisition of many subsequent skills (e.g., pivotal responses, behavioral cusps).


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Vocabulary as a Critical Skill

  • Children in advantaged homes are exposed to, and learn two to three times as many words as those in disadvantaged homes (Hart and Risley, 1995).

  • Correlation of .78 between parents use of “non-business” words with their kids and later IQ

  • This discrepancy between advantaged and disadvantaged children is not ameliorated through schooling.


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20000

18000

16000

14000

Advantaged Children

12000

Vocabulary Size

10000

8000

6000

Disadvantaged Children

4000

2000

0

1

2

3

4

5

6

7

8

9

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18

Age


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Vocabulary as a Critical Skill(continued)

  • Vocabulary in the early school years is the single, best predictor of SAT scores and adult literacy.

  • This is why Andy Biemiller has called vocabulary the Missing Link between reading mechanics and reading comprehension or literacy.


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Vocabulary and Reading

  • Read the following word and raise your hand when you know what it is:

    • supercalifragilisticexpialidocious


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Individualized Vocabulary Lists with Normative Relevance

  • Normative word lists provide information on words that most children know

  • Individualized word lists contain words that a child contacts on a routine basis

  • Identifying words common to both types of lists may produce the larger increases in the child’s working vocabulary


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Developing an Individualized Vocabulary List

  • Begin with a word list with a developmental progression

    • Living Word Vocabulary; (Dale & O'Rourke, 1981)

    • http://www.sci.sdsu.edu/lexical/select.php; (Dale & Fenson, 1996)


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Developing an Individualized Vocabulary List (continued)

  • Identify words that the child is likely to contact on a daily basis

    • Morning Routine

      • Places, people, activities, items

    • Mealtime

      • Foods, utensils, kitchen and dining room items

    • Playtime

      • Toys, activities, people


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Developing an Individualized Vocabulary List(continued)

  • Daycare or school

    • People, actions, objects

  • Places like church, stores, restaurants

    • What is done there, What they sell, What you buy

  • Household chores and activities

    • What they are called, Who does them


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Developing an Individualized Vocabulary List(continued)

  • Special events

    • Birthdays, holidays, vacations

  • Sports and hobbies

    • Materials used, players, positions, What they do

  • Things in the yard and neighborhood

    • Animals, trees, vehicles, names of neighbors


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Developing an Individualized Vocabulary List(continued)

  • Keep a 3-day diary and write down the names of people, objects, activities, and actions and add any new words to your list


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Developing an Individualized Vocabulary List(continued)

  • Enter the individualized list into a spreadsheet next to the normative word list

  • Sort both lists alphabetically

  • Identify words common to both lists

  • Re-sort the lists developmentally

  • Begin teaching common words ordered developmentally


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Behavior Analytic Approaches to Vocabulary Development

  • From a behavior analytic perspective, teaching vocabulary involves the establishment of specific types of conditional discriminations, ones involving a spoken or written word as component of the four-term contingency.


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Conditional Discriminations Involving Deictic Words

  • Children with autism have particular difficulty learning deictic words because they require conditional discriminations (or have shifting referents).

  • Examples: I, you, me; first, last; this, that; here, there.


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Conditional Discriminations Involving Social Skills

  • Social approaches to other individuals are likely to produce reinforcement under certain conditions and not others (e.g., requests to play when a parent is busy or not).

  • Interactive play and joint attention require the child to simultaneously attend to objects and people.


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Three- and Four-Term Contingencies

Stimulus – Response – Reinforcer

Conditional Stimulus – Stimulus – Response – Reinforcer

  • With spoken-word-to-picture discriminations, a spoken word is the conditional stimulus that specifies which of the comparison stimuli the individual should respond to produce reinforcement.



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Building Working Vocabularies

  • Spoken-word-to-picture discriminations are critical to the development of vocabulary skills.


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Functional Approaches to Teaching Conditional Discriminations in Autism

  • Unmotivated learners

  • Learners requiring extra-stimulus prompts

  • Inattentive learners

  • Severely limited learners


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Baseline Discriminations in Autism

Sr+

Sr+ + Prompt

100

90

80

70

Prompted

60

correct

Percent Correct

50

responses

s

40

30

20

10

CB

0

2

4

6

8

10

12

14

16

18

20

Sessions


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Baseline Discriminations in Autism

Sr+

Sr+ + Prompt

100

90

80

70

60

Percentage of Attending

50

40

30

20

10

CB

0

2

4

6

8

10

12

14

16

18

20

Sessions


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Teaching Conditional Discriminations to Inattentive Learners Discriminations in Autism

  • Extend prior work on differential observing responses (DORs) by embedding an identity-matching task into a graduated-prompting procedure to teach spoken-word-to-picture relations to children with autism.


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Treatment and Control Conditions Discriminations in Autism

  • Control

    • Verbal prompt to point to test stimulus

    • No feedback for correct or incorrect responses

  • Graduated prompting

    • Sequential verbal, modeled, and physical prompts

    • Praise and edible delivered for correct response following the verbal prompt

  • Identity-matching

    • Identical to graduated-prompting except the modeled prompt was replaced with an identity-matching task

    • ID prompt: Therapist held up a picture identical to the test stimulus and said, “This is Alex. Point to Alex”


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100 Discriminations in Autism

90

Graduated

Prompting

Identity Matching

80

70

60

50

Percent Correct

40

30

20

10

Control

Jane

0

0

5

10

15

20

25

30

35

40

Sessions


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100 Discriminations in Autism

90

80

70

60

Graduated Prompting

Identity Matching

50

Percent Correct

40

30

20

10

Danny

0

0

5

10

15

20

25

30

35

40

Sessions

Control


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Teaching Vocabulary in Autism Discriminations in Autism

  • These cases illustrate how identifying the functional deficit responsible for a child’s poor performance on spoken-word-to-picture relations can be used to develop an effective intervention to improve the child’s working vocabulary.


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Vocal Mand Assessment and Training (Bourret et al., 2004) Discriminations in Autism

  • Conducted a preference assessment to identify a high preference item

  • Conducted mand assessment to identify the appropriate training procedure

  • Conducted mand training using the identified procedure


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Behavioral Approaches to Verbal Behavior Discriminations in Autism

  • In traditional approaches to speech and language, the focus is on the topography of verbal behavior or what it looks like (e.g., receptive, expressive, phonemes, words, phrases, sentences).

  • Behavioral approaches focus on the functional aspects of verbal behavior (e.g., echoic, mands, tacts, intraverbal, autoclitic).


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Behavioral Approaches to Verbal Behavior Discriminations in Autism(continued)

  • Verbal behaviors are learned responses that are defined in terms of the antecedents and consequences of which the behavior is a function:

    Antecedent Behavior Consequence


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Echoic Responses, Mands, Tacts, Intraverbals Discriminations in Autism

Antecedent Behavior Consequence

“Ball” “Ball” “Good job”

Ball on shelf “Ball” Ball given

Ball shown “Ball” “That’s right”

“What is round “Ball” “That’s right”

and bounces?”


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Vocal Mand Assessment Discriminations in Autism

  • Each session involved 10 1-minute trials

  • 0 s: No Prompt

    • Hold the high preference item in front of the child

  • 10 s: Nonspecific Prompt:

    • “If you want this, ask me for it.”

  • 20 s: Modeled Prompt:

    • “If you want this, say chip.”

  • 30 s: Phoneme Prompt:

    • “If you want this, say “ch.”

  • Give the high preference item for the remainder of the trial following a correct response.


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PROPORTION OF TRIALS Discriminations in Autism

NonspecificPrompt


Slide101 l.jpg

| FADING | Discriminations in Autism

Nonspecific

Prompt

“Nick”

“Ni”

PROPORTION OF TRIALS


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Social Skills Training Discriminations in Autism

  • Identify one or more peers who are willing to help promote social behavior

  • Identify activities that both your child and the peer enjoy

  • Possible activities include: rolling a ball, Lego blocks, basketball and hoop, puzzles, musical instruments, crayons, play dough, dressing up in costumes, duck-duck-goose, ring-around the rosy, trucks and cars


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Social Skills Training Discriminations in Autism(continued)

  • Practice the activity with your child and note any prompts, reinforcers, or assistance you provide.

  • Before the activity starts, teach the peer to deliver the same prompts, reinforcers, and assistance as you did when you practiced with your child.


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Social Skills Training Discriminations in Autism (continued)

  • Supervise the initial session closely and deliver praise and preferred items for appropriate social behaviors like,

    • Smiling

    • Initiations, spoken or gestured (“Look”, “Watch me”, “Your turn”, “My turn”)

    • Turn-taking and sharing


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Initial Toilet Training Discriminations in Autism

  • Prompt the child to go into the bathroom and pull down their pants.

  • If the child is wet or soiled, clean and change them with minimal attention (don’t talk to the child) and then leave the bathroom.

  • If the child is dry, have them feel their underwear and praise (“Good job! Your pants are dry.”)

  • Have the child sit on the toilet and immediately deliver their most preferred reinforcer and then allow the child to get off the toilet and leave the bathroom.


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Initial Toilet Training Discriminations in Autism(continued)

  • Keep a log and record whether the child was wet, soiled, or dry, and whether they voided in the toilet.

  • Repeat 9 more times (or trials), once every ½ hr.

  • For the next 10 trials, set a kitchen timer and have the child sit on the toilet until the timer goes off and then deliver the reinforcer.

  • Mix up the lengths of the toileting sits (e.g., starting with 5, 8, 6, 10, 7, 9, 6, 9, 5, 10, 8, and 7 seconds).

  • If at any point, the child voids in the toilet, immediately praise, deliver the reinforcer and allow them to get off the toilet and leave the bathroom.


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Initial Toilet Training Discriminations in Autism(continued)

  • Get the child used to the toilet (cont.).

    • For the next 10 trials, double the lengths of the toileting sits (e.g., 12, 14, 10, 18, 16, 20, 12, 18, 10, 16, 20, and 14 seconds).

    • Continue doubling the lengths of the sits until the child is sitting on the toilet for 5 minutes once every ½ hr.

    • When ½ of the child’s voids are in the toilet, stop providing reinforcement for completing 5-minute toileting sits without voiding (i.e., only voiding in the toilet produces reinforcement).


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This presentation can be located at: Discriminations in Autism

www.unmc.edu/mmi

(select the link Departments then

Center for Autism Spectrum Disorders)


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