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Training on Autism

Kimberly Ball Davis - Friendswood Indpendent School District
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Kimberly Davis

on 11 October 2014

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Transcript of Training on Autism

AutismSpectrum Disorders -
Learning that our students are not from outerspace

FOCUS
SEARCHING
Assessment
Strategies

Characteristics of ASD
UNDERSTANDING
Symptoms of ASD

OK, but what IS ASD?
*ASD originates in the brain
*Nuero-develpment brain-based disorder
*Affects social interaction, verbal and nonverbal communication and repetitive behaviors.
*Can be diagnosed by the age of 2, but often times, symptoms of autism can be seen as early as 6-8 months.
Pay Attention to Details
Children with ASD may exhibit these signs which signal red flags in typical development.
Listen
Do you know the financial costs of ASD?
One of the myths of autism is that children have an inability to show attachment, but studies say ASD children do, just in a different ways. One of the difficulties is the fact that children with ASD find it hard to read body language, facial expressions and voice inflection.

How is this a challenge in the classroom?

How can you help in the classroom with social deficits?
Build a relationship with your student. yes yes yes!!!
Understand where his skill set is
Understand that unstructured times are most difficult so provide structured activities during recess, etc.
Model social interaction and point out good models in the classroom.
Have a peer with good social skills be his partner
Teach social skills classes to promote social boundaries, listening skills, anger management, context clues (if everyone is standing, you stand too.)
Teaching about empathy.


Three of the types of intervention are:
Applied Behavior Analysis
Sensory Integration Therapy
and
Medication
One aspect of therapy in ABA:
Stopping the behavior: It the team decides it would be best to stop the behavior, often times it is most effective to find a replacement behavior that will not interfere with the learning process or have as much social stigmatization. If the behavior is intrisically motivating, it is usually not effective enough alone to ignore the behavior. The teachers should not give any reactions or input to the child when they are exhibiting the behavior. When the student has stopped, positive input is greatly encouraged.
Each time the child is at the pediatrician, from birth to 36 months, there should be a screening for developmental milestones. Diagnosis is most often based on the criteria in the DSM-V.

There are a number of professionals who can confirm the diagnosis. (Always make sure you are working with an experienced professional.)
-Pediatrician
-Psychologists
-Neurologist
-Psychiatrists

Early diagnosis is so very important because early intervention has proven to be the most effective.

This does not mean that if you have a student in your classroom who is exhibiting signs, that he does not have autism. Sometimes, as children get older, social and/or academic deficits become more evident and the you may wish to talk to your Licensed Specialist in School Psychology about your concerns.
For school purposes, there is a difference between diagnosis and eligibility. The Individuals with Disabilities Education Act (IDEA) requires that public schools provide assessment, free of cost, to determine eligibility for services through the school. Assessment is made by an interdisciplinary team working together to determine eligibility in determining disability that affects communication and social interaction.
Discussion of Augmentative and alternative communication (AAC):

What are AAC's?

They are systems that can be aided or unaided to help students who can't use verbal speech communicate with others. Some types of ACC include gestures, sign language, picture symbols, and speech generating devices.
RRB's are often reported as the most difficult for teachers to manage because of their interference with daily activities. And, unfortunately, they make it difficult for socialization with their peers and even adults. They often impede the learning process at school and home.
K - W - L / Autism
Fact on
Autism Spectrum Disorder.
Autism Spectrum Disorder is a new name given to autism, aspergers, pervasive developmental disorder, and childhood disintegrative disorder. There is not any delineation of disorders since the new DSM-5 came out in 2013. ASD is the scientific consensus that now encompasses all of the disorders. It affects one in 68 children. This reflects an increase of 10-17% increase in diagnoses and surprisingly 1 in 54 boys as compared to 1 in 252 girls. Although some of the reason for the increase is due to awareness and new screening procedures, the growing number cannot all be attributed to this.

A parent may ask you about ASD?
What do you tell them?
Do you know the signs that could signal a possible delay?
What types of interventions might be used at school?
What advice can you give me about helping my child at home?

These questions seem quite overwhelming, but giving parents good information is essential and can be the beginnings of a team working towards the goal line,
......together.

Copyright
Don't
Stop
Learning!
Licensed for Creative Commons
Attibution Non-Commercial Share Alike
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Preparing for your future.
*Family cost a year - $60,000 - $80,000
*Added cost in healthcare and education per family - $17,000 (largest part of this was education cost, then healthcare)
*National cost for healthcare and education - exceeded 11.5 billion in 2011
*National cost of ASD care per year - 137 billion (majority of this in adult life)
*Average lifetime cost per person per year - 1.4 million
*Interestingly, mothers who have ASD children make 54% less than their counterparts.
Are you still asking why early intervention is SO important?


Effective early intervention can clearly pay for itself as well as better the lives of those living with ASD and their families.
Way before babies begin to speak, they communicate their needs, wants, and interests with others through a combination of vocalizations, facial expressions and various non-verbal gestures.
One of the earliest signs of social interest in others is the typical newborn’s preference for the human voice over other sounds.

While typically developing children are attentive to others and show social behaviors at a very early age, individuals with autism often exhibit difficulty engaging in social interactions throughout their lifetime.


One aspect of this is using joint attention. This occurs when infants are able to self-organize social information. In doing so, learning is promoted in structured and incidental learning opportunities. Joint attention is a necessary skill for cognitive skills such as social referencing, language acquisition and learning through modeling behaviors of others around you. Without the ability of joint attention, children would not be able to learn how to speak or get their parents attention when they want something. Joint attention is also important for later skills, like more complex expressive language and symbolic play.

Social interaction deficits are a core deficit of autism. Some suggest that the presence of deficits in reciprocal social behavior distinguishes autism from other psychiatric disorders.
Social Deficits?
What are repetitive behaviors in children with autism?
The criteria for the new DSM-5 category of Autism Spectrum Disorder (ASD) will continue to include RRB as a core diagnostic feature, together with the domain of social communication and social interaction deficits. According to the DSM-5, restricted, repetitive patterns of behavior, interests, or activities are defined by the presence of at least two of the following:

Stereotyped or repetitive speech, motor movements, or use of objects are RRB's. Some of the most common repetitive behaviors you can visually see the ASD child experience. They are: hand-flapping, rocking, jumping and twirling, arranging and rearranging objects, and repeating sounds, words, or phrases

Often times ASD children use self stimulation (stimming). This is also a type of repetitive behavior, like turning circles, spinning. ASD children may play with toys in an odd manner. Rather than using cars or blocks for pretend play, children with autism may prefer to line up toys according to attributes such as shape, size, or color. Children with autism may also become preoccupied with one part of a toy and their toy play may become restricted (e.g., spinning the wheel of a toy truck over and over).

Self-injurious behaviors like picking, biting, and headbanging are types of RRB's.

RRB's are not limited to physical behaviors. They can extend elsewhere. One type is repeating spoken word, called echolalia as well as ritualized sayings and idiosyncratic phrases

Sensory input is also included in RRB"s. 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.

Interestingly, obsessions or intense preoccupations can also be a type of repetitive behavior. I had one student who could tell you every fact known about the black plague. Sometimes the topic or focus can seem odd. Excessive adherence to routines and highly restricted interests that are not normal.

And this is why we do what we do!
(Get your tissue out.)
RRB's - Repetitive and Restrictive Behaviors

Turn to your neighbor and discuss what types of RRB's you have experienced in your classroom.

Any new behaviors we haven't talked about?

Now, in groups of four or five, brainstorm about what interventions you have provided in the classroom and we will discuss what was most effective for you.
Why RRB's
Whenever we are looking at behaviors of any kind, we want to ask ourselves, what is the function of that behavior?

I've been on a tunafish and apple diet for 10 days and lost just as much weight. Then I had a cupcake late last night. What do you think the function of that behavior was.

Function of RRB's may be that they are intrinsically rewarded by the spinning, pacing, handflapping. Students with an understimulated nervous system may need some type of vestibular input (nervous system arousal), and the stimming provides this. Then the student may even find it more rewarding if the teacher tries to get him to stop and then the behavior has been reinforced. Another possible explanation may be the children that are hypersensitive need a norming behavior. This allows the student to control one specific part of his hypersensitive world, and the behavior becomes a soothing one.


Another use of ABA for intervention is shaping.
When the team determines what behavior the target is, they will work together to modifying the behavior over time until the unwanted behavior is replaced by the desired behavior. Immediate redirection and immediate positive reinforcement is required. An example might be a student who is hitting his head, the teacher would say, "Stop hitting, Mikey. Quiet hands." The teacher would then help him put his down. Immediate praise for the student is then expected.
Have you seen the pink lights in my room?
Another intervention could involve sensory integration therapy.
The use of sensory integration therapy involves the stimulation of the sensory system. If the students nervous system can be stimulated through regulated procedures, there may less need for the self stimulation. Activities affecting the vestibular system like swinging, spinning, hanging upside down involve the head moving in different ways and can stimulate the vestibular system. Sight and sound can also be used. Some children are stimulated by bright colors, and long straight lines are often preferred. Back to those pink lights. Bright lights are often difficult for our students to manage. Having soft light may help with the student being OVER stimulated and then using a stimming behavior to modulate his environment. Sound is the same principle. Loud sounds are often aversive and the student begins stimming. Soft sounds used or soft music may help.
What to you find that most
frustrates your student?

I find that my students are most frustrated when they are not able to express their wants and needs. AAC's are effective in helping students facilitate their communication regardless of any cognitive, behavioral, or language deficits.

So many ASD students can benefit from augmentative communication tools and strategies.

"According to Krumboltz, career counseling should not end when a person has decided on a course of action. Rather, the person will need to look for a job, perhaps experience rejection, deal with positive and negative aspects of a job, and have to deal with new unforeseen proplems and possible crises that may arise following through on a plan of cation. Krumboltz believes that it is the counselor's role to help the individual take action, as well as decide on a course of action." (Sharf, 2010)
Medication
If the students' medical provider believes the RRB's are a result of a neurological or chemical imbalance, the use of medications may be effective. Similarly, if anxiety is the cause of the RBB's, medication is precribed to control the RRB's. The most commonly prescribed medications are the selective serotonin reuptake inhibitors (SSRIs). The use of medication alone is not preferred. Medication combined with the use of ABA behavioral modification interventions and sensory integration is preferred.
The ranges vary....many of you may have worked with kids on both ends of the disorder.
What degrees of ASD of have you witnessed at school?
The fictional character, Max, is diagnosed with ASD and we see a range of behaviors.
Most parents of ASD children become concerned about their child's progress by the age of two, but signs can be detected much earlier. Most children with more severe symptoms, can be diagnosed by the age of two. But, some children are typically developing and then begin to lose skills they have mastered.
Typically Developing Children:
*2 Months: Smiles at the sound of your voice and follows you with their eyes as you move around a room
*3 Months: Raises head and chest when lying on stomach
Grasps objects. Smiles at other people
*4 Months: Babbles, laughs, and tries to imitate sounds; holds head steady
*6 Months: Rolls from back to stomach and stomach to back
Moves objects from hand to hand
*7 Months:: Responds to own name. Finds partially hidden objects
*9 Months: Sits without support, crawls, babbles "mama" and "dada"
*12 Months: Walks with or without support. Says at least one word. Enjoys imitating people.
*18 Months: Walks independently, drinks from a cup, says at least 15 words, points to body parts
*2 Years: Runs and jumps. Speaks in two-word sentences. Follows simple instructions. Begins make-believe play.
*3 Years: Climbs well. Speaks in multiword sentences. Sorts objects by shape and color.
*4 Years: Gets along with people outside the family.Draws circles and squares.
*5 Years: Tells name and address. Jumps, hops, and skips.
Gets dressed.Counts 10 or more objects.
No big smiles or other warm, joyful expressions by six months or thereafter
No back-and-forth sharing of sounds, smiles or other facial expressions by nine months
No babbling by 12 months
No back-and-forth gestures such as pointing, showing, reaching or waving by 12 months
No words by 16 months
No meaningful, two-word phrases (not including imitating or repeating) by 24 months
Any loss of speech, babbling or social skills at any age
Do you see social deficits with ASD children in your classroom?
Children with social deficits may have:
Difficulties understanding the facial expressions of others
Difficulties with or complete lack of initiating social interactions with others

Lack of responding to social initiations made by others
Lack of responding to the emotions of others
Deficits in showing
Lack of interest in other children

Absence of or limited use of gestures such as pointing to share enjoyment with others

Absence of or limited imitation skills

Lack of friendship seeking behavior


Research has also shown that the social interactions of individuals with autism are significantly different from those with other developmental disabilities like Down syndrome. Individuals with autism have been found to be less likely than those with other developmental disabilities to orient to social stimuli, to respond to the social bids of others, and to initiate social interactions with others (joint attention.)
(Constantino & Todd, 2003)
(Center for Autism Spectrum Disorders, 2014)
Autism Speaks, 2014
autism-help.org
autism-help.org
autism-help.org
May stimulate brain development
Supports functional spontaneous communication
Facilitates access to social information
Facilitates inclusion at home, school, and community
Facilitates greater independence in the home, school, and community
Facilitates access to literacy experiences
Preempts the need to develop aberrant communicative behaviors (reduces meltdowns)
Provides voice and ears to people with autism, including psychological benefits of better understanding others and being understood
Facilitates an improved sense of self concept due to greater independence and fewer outbursts
Why do you think this is?
Types of AAC's include no tech, low tech, mid tech, and high tech.

No tech: does not require a power resource (uses body gestures, etc.)

Low tech: power source and easy to use without training (like PECS - picture exchange system)

Mid tech: power source and requires some training

High tech: power source, expensive and requires extensive training.

The last three can have digitized speech (more natural sounding) and synthesized speech.
Cafiero, J., Meaningful Exchanges for People with Autism
Califero, J., Meaningful Exchanges for People with Autism
Assessment for Autism
As soon parents feel there might be something different, they should discuss their concerns with their pediatrician. Some of these concerns would include their child failing to make eye contact with them, repetitive movements with their body or toys, and not responding to their name. The Modified Checklist of Autism in Toddlers (M-CHAT) can be taken online at http://www.autismspeaks.org/what-autism/diagnosis/screen-your-child. The tool may guide you in being able to make a decision if you should refer to a professional.
Autism Speaks, 2014
www.gvsu.edu
Private Sector Public School
www.gvsu.edu
http://www.cdc.gov/ncbddd/autism/hcp-screening.html
Screening tools are meant to be a tool in the diagnosis process. It should be understood that the tools are just the beginning part of the assessment. It the tool indicates any deficits, then a full assessment should be administered.

Choosing the correct screening tool should consist of; considering the needs of the student, what types of delays are you trying to determine, the psychometric properties of the test (it does and measures what it says it will), setting in which the screening will be administered.
If a screening indicates a deficit, a professional will choose a diagnostic tool in the same manner as choosing the screening tool.

Diagnosis should not be made upon the determination of one screening tool. These tools usually use two or more sources of information to receive information from, like parents or caregivers information about their child and then it is combined with professional observations of the student.


Diagnostic Tools
• Autism Diagnosis Interview: Revised
(ADI-R) A clinical diagnostic instrument for assessing autism in children and adults. The instrument focuses on behavior in three main areas: reciprocal social interaction; communication and language; and restricted and repetitive, stereotyped interests and behaviors. The ADI-R is appropriate for children and adults with mental ages about 18 months and above.
• Childhood Autism Rating Scale (CARS): Brief assessment suitable for use with any child over 2 years of age. CARS includes items drawn from five prominent systems for diagnosing autism; each item covers a particular characteristic, ability, or behavior.
Centers for Disease Control, Autism.
Center for Disease Control, Autism. http://www.cdc.gov/ncbddd/autism/hcp-screening.html
• Autism Diagnostic Observation Schedule – Generic (ADOS-G): A semi-structured, standardized assessment of social interaction, communication, play, and imaginative use of materials for individuals suspected of having ASDs. The observational schedule consists of four 30-minute modules, each designed to be administered to different individuals according to their level of expressive language.
Center for Disease Control, Autism. http://www.cdc.gov/ncbddd/autism/hcp-screening.html
Center for Disease Control, Autism. http://www.cdc.gov/ncbddd/autism/hcp-screening.html
Gilliam Autism Rating Scale – Second Edition (GARS-2): Assists teachers, parents, and clinicians in identifying and diagnosing autism in individuals ages 3 through 22. It also helps estimate the severity of the child’s disorder.
Autism Treatment Evaluation Checklist (ATEC):
The Autism Research Institute (ARI) has developed this simple Internet scoring instrument (containing 77 items) that provides subscale scores and a summary score. Although designed to evaluate the effectiveness of treatments for autism, it may also prove useful for screening and diagnosis in children ages 5-12. Since the ATEC is a simple one-page form that can be copied freely and scored immediately (currently at no cost), it might be very useful as a diagnostic tool.

Example of Autism Treatment Evaluation Checklist-
Lets pick a student a fill out the checklist.
Whatever screenings or tools that are used, remember in the public schools, the interdisciplinary team will make the diagnosis. Diagnosis' should be made only by trained clinicians after complete evaluations of the student or child.

ABA
What is ABA?
ABA is the utilization of behavioral strategies that target individual behaviors of people with ASD. Through the use of ABA, target skills are identified and then learned over time until the skill in acquired and can be used in the natural setting. Deficit skills are also identified and through the use of behavioral strategies in ABA, these maladaptive behaviors can be reduced. Although there is not one ABA "program," there are several components that make ABA treatment productive.
Say that again....
Autism Speaks Autism Treamentnetwork
ABA applies the principles of behaviorism to make meaningful changes in the lives of individuals.
How would I implement ABA in the classroom?
You, as the teacher, need to define the students IEP goals by evaluating what the student needs to work on most, and according to his appropriate TEKS. The goals must be measurable and observable. The teacher must then implement the goals using evidence-based behavioral methods and then collect data to determine if the intervention was effective.
Leach, D., (2010). Bringing Evidence Based Practices into the Inclusion Classroom
Leach, D., (2010). Bringing Evidence Based Practices into the Inclusion Classroom

What would that look like?
Although the following clip was made for a ABA consultant company, it shows a good example of implementing ABA into a public education classroom and some of the components that are essential for that classroom.
Terms teachers should be familiar with in an school with an ABA program.
An approach to learning that uses corresponding rewards and punishments are linked to behaviors and learning occurs by making association between the behavior and either the rewards or punishments for that behavior.
Operant Learning
Often known as the ABC chart (antecedent, behavior, consequent). It is a three-part model that says behavior is learned and influence by antecedents and consequence.
The three-term contingency
Antecedents are our cues for behavior. They are the events (the who, what, and where) that occur immediately before a behavior

Antecedents
Consequence
Consequent events are events that typically follow behavior and are necessarily viewed by the child as contingent upon behavior.The presence or absence of events after the behavior makes it
more or less likely that a behavior will happen more or less frequently.

Establishing operations have a value altering (momentarily alters the effectiveness of reinforcers/punishers) and behavior altering effects (momentarily evokes or abates behavior).
Establishing Operations
The process of breaking down a complex task
into its smaller steps or components. Tasks with many steps or components may be divided into phases for teaching purposes
Task Analysis
Is a one-to-one instructional approach used to teach skills in a planned, controlled, and systematic manner. DTT is used when a learner needs to learn a skill best taught in small repeated steps.Each trial or teaching opportunity has a definite beginning and end, thus the descriptor discrete trial
Discrete trial training (DTT)
http://autismpdc.fpg.unc.e du/content/discrete-trial-training-0
Is the current level that a target behavior occurs prior to intervention. It is absolutely essential to obtain baseline information prior to the onset of an intervention. It is only with measure prior to an intervention compared to data collected after the intervention begins, that the effectiveness of the intervention can be determined
Mouzakitis, 2007
Baseline
Is when something that has already been earned gets removed. You can think of it as a tax on behavior. Response cost is a type of punishment; therefore in order for a response cost procedure to be effective, the target behavior must decrease the future probability of occurrence. If the rate of behavior goes up or remains unchanged after wards, then it is not by definition a response cost.
Potterfield, 2013
Response Cost
EIBI is designed to work with young children in intensive settings using behavioral principles. EIBI involves a high intensity (number of hours as well as reliability) of intervention. EIBI can include discrete trial teaching, natural language teaching, social stories, video modeling, as well as other types of ABA-based strategies.
Early Intensive Behavior Intervention (EIBI)
Autism Speaks, 2013
ABA therapies are:
Structured
Collect data for target skills or behavior
Provide positive strategies for changing responses and behavior

Autism Speaks Autism Treatmentnetwork
Therapies Based on
ABA Therapies
Antecedent-based interventions
Computer aided instruction
Differential reinforcement
Discrete trial training
Extinction
Functional behavior assessment
Functional communication training
Naturalistic interventions
Parent-implemented intervention
Peer-mediated instruction/intervention
Picture Exchange Communication System
Pivotal response training
Prompting
Reinforcement
Response interruption
Self-management
Social narratives
Social skills training groups
Speech generating devices
Structured work systems
Task analysis
Time delay
Video modeling
Visual supports
All of these therapies are structured, some highly structured, they require data to be taken to measure growth in target skills, goals, and behaviors, and they provide strategies for changing responses and behaviors. ABA focuses on positive reinforcement strategies. These therapies can help students who are having difficulty learning or acquiring new skills, or behavioral difficulties.

There are several ways ABA can be implemented in
the classroom.
Incidental Teaching (or Natural Environment Training)
Based on the understanding that it is important to give real-life meaning to skills a student is learning. It includes a focus on teaching skills in settings where your child will naturally use them. Using a child’s natural everyday environment in therapy can help increase the transfer of skills to everyday situations and helps generalization. In Incidental Teaching, the teacher utilizes naturally occurring opportunities in order to help the child learn language. The activity or situation is chosen by the child, and the teacher follows the child's lead or interest. These teaching strategies were developed to facilitate generalization and maximize reinforcement.
Verbal Behavior
is similar to discrete trial training in that it is a structured, intensive one-to-one therapy. It differs from discrete trial training in that it is designed to motivate a child to learn language by developing a connection between a word and its meaning. For some children, teaching a word or label needs to include a deliberate focus on
teaching them how to use their words functionally (e.g. What is this? A cup. What do you use a cup for? Drinking. What do you drink out of? A cup.)
Autism Speaks Autism Treatmentnetwork
Autism Treatment Autism Network
Pivotal Response Training
A naturalistic, loosely structured, intervention that relies on naturally occurring teaching opportunities and consequences. The focus of PRT is to increase motivation by adding components such as turn-taking, reinforcing attempts, child-choice, and interspersing maintenance (pre-learned) tasks. It takes the focus off of areas of deficits and redirects attention to certain pivotal areas that are viewed as key for a wide range of functioning in children. Four pivotal areas have been identified: (a) motivation, (b) child self-initiations, (c) self management, and (d) responsiveness to multiple cues. It is believed that when these areas are promoted, they produce improvements in many of the non-targeted behaviors.
Autism Speaks Autism Treatmentnetwork
Natural Language Paradigm (NLP)
Based on the understanding that learning can be helped by deliberate arrangement of the environment in order to increase opportunities to use language. NLP emphasizes the child’s initiative. It uses natural reinforcers that are consequences related directly to the behavior, and it encourages skill generalization. For example, a child who is allowed to leave after being prompted to say “goodbye” has a greater likelihood of using and generalizing this word when compared with a child who receives a tangible item for repeating this word. NLP transfers instruction from the therapy room to the student's everyday environment with the interest of the child serving as the starting point for interventions.

Discrete Trial Learning (Training)
Based on the understanding that practice helps a child master a skill. It is a structured therapy that uses a one-to-one teaching method and involves intensive learning of specific behaviors. This intensive learning of a specific behavior is called a “drill.” Drills help learning because they involve repetition. The child completes a task many times in the same manner (usually 5 or more). This repetition is especially important for children who may need a great deal of practice to master a skill. Repetition also helps to strengthen long-term memory. Specific behaviors (eye contact, focused attention and facial expression learning) are broken down into its simplest forms, and then systematically prompted or guided. Children receive positive reinforcement (for example: high-fives, verbal praise, and tokens that can be exchanged for toys) for producing these behaviors. For example, a teacher and a child are seated at a table and the teacher prompts the child to pay attention to her by saying “look at me.” The child looks up at the teacher and the teacher rewards the child with a high-five.
Autism Speaks Autism Treatmentnetwork
The Texas Statewide Leadership for Autism states that a significant amount of research supports the use of discrete trial training with individuals with autism (AU) in a variety of settings, including the school setting. Discrete trial training can help ASD students compensate for the challenges they face. Some of the benefits are:
• In discrete trial training, tasks are broken down into short and simple trials that accommodate the needs of individuals with short attention spans.
• Discrete trial training attempts to build motivation by rewarding performance of desired behavior and completion of tasks with tangible or external reinforcement.
•Stimuli presented in discrete trial training are clear and relatively consistent. The child is given rewards only for behaviors in response to those stimuli.
Discrete trial training teaches skills and behaviors explicitly (cause-effect learning).
• The instructions given in discrete trial training are simple, concrete, and clearly provide only the most salient information.
• Discrete trial training can be designed to teach perspective taking and social cognition skills explicitly


(DTT information from
Texas Statewide Leadership for Autism, 2012).
In Discrete trial training, a learning opportunity is presented to the student where his correct response will be reinforced with the A-B-C model, as demonstrated here.
DTT takes a task or process a student needs to learn and breaks it down into small steps that can be gradually added upon. Most often, DTT takes place in a one to one ratio with the teacher and the student, but can also work with group instruction. The teacher prompts the student to do a specific action, and if the student is successful, he is rewarded with positive reinforcement (as seen in the video.) Based on the A-B-C model:
A (antecedent) - a directive or request for the child to perform
B (behavior) - a behavior, or response from the student, either successful performance, noncompliance, or no response
C (consequence) - reaction from the teacher, which can range from verbal praise, high five, treat, or negative response, "no."
Synapse
How Do Discrete Trials Work?
The components of discrete trial.
Instruction (generally a command or request, but it may be also a visual stimulus)
Prompt (assistance given to promote a correct response, it may not occur in all trials)
The students response
Feedback or other consequences (most commonly rewards and/or praise)
Interval (a few seconds between trials for the child to process information)
Synapse
DTT is a time intensive program. One downside of DTT is the fact that it can become very expensive. Ideally, intervention should begin when the child is 2 or 3 and can be extended in our school. The first stage includes:
Self-help and receptive language skills
Nonverbal and verbal imitation
Appropriate play
The next phase would focus expressive language and interactive play with peers.
Academic tasks
Socialization skills
Cause-effect relationships
Learning by observation
During this phase, group instruction could begin. With group instruction, learners also have the opportunity to work with others, learn social skills, and can even learn to pick up on cues the other students are giving.

Choral instruction - the group is instructed to respond all at once

Overlapping instruction - a trial begins with one student and then moves to next students (one students doesn't know answer, next student is given same question and the first student can use his modeling to learn from)

Data can be collected for IEP and social skills.
Using Promts
Giving students effective prompts gives them helps them give correct responses. The teacher can provide prompts during errorless teaching, while the student is responding (to help give correct response), and after an incorrect response (or no response).

Prompting can begin with the most assistance and gradually "fade" the prompts. From physical, modeling, gesturing, to verbal prompts.

One goal of effective prompting is to gradually decrease the prompting, so students will be more likely to generalize skills.


All of these components of ABA, provide students with the learning opportunities to learning and communication skills. Students are able to improve attention, focus, follow directions, improve social skills and academics, as well as have a reduction in their maladaptive behaviors. One important difference of ABA and other therapies is the fact that the American Psychological Association and the US Surgeon General consider it a best practice and evidence based. This indicates that the methods of ABA have been proven effective through scientific tests of its usefulness and quality.
DTT, along with ABA interventions, provide students with learning opportunities that aim at shaping behavior and teaching skills.

These therapies, have been proven to be learner centered and evidence-based. Some of these interventions are:
Are there other interventions in
treating ASD?
Yes, of course, but as we just discussed, ABA therapies have proven to be most effective.

That is not to say that other interventions are not effective.

Many of these models have some components of ABA in them, but do not include all of them.
One educational model is Training and Education of Autistic and Related Communication Handicapped Children (TEACCH). It is based on structured teaching and focuses on a individualized plan for each student. The student's IEP's are worked on by identifying strengths and building upon them. The environment is arranged visually and structurally in such a way that the student can easily predict his daily activities. ASD students function well in this environment, but as opposed to ABA, it may be more difficult to generalize skills.
Another educational intervention is Social Communication/Emotional Regulation/Transactional Supports (SCERTS). It focuses on developing functional social communication, developing the ability to cope with daily stresses, and providing supports in the environment to meet the ASD students' needs. The students are generally taught in with other students, allowing them learn from peer modeling. SCERTS differs from ABA in the fact that it promotes child initiated communication. One disadvantage of SCERTS is that while most ABA therapies can be modifies to use in the home environment, it would be difficult to do this with SCERTS.
Other interventions deal with the biological and medical conditions that are associated with ASD.
Speech and Language Therapy (SLT) is designed to help ASD students understand the meaning of language. SLT can also address issues with the mechanics of speech. SLT can be implemented in classroom settings, small group and one to one. The main focus is to help the student be able to have functional communication.
Occupational Therapy (OT) helps students with cognitive, physical and motor skills be able to gain independence and participate in such basic things in daily activities like dressing, all the way to helping the student use motor skills needed to write legibly.
Sensory Integration (SI) is designed to identify disruptions in the way the student processes movement, touch, smell, sight and sound. Through SI the students is taught to process their senses in a more productive way. It can help the students with transitions, behaviors, and be able to tolerate things the student finds aversive. Many times it is used along with OT.
These therapies are very helpful in treating aspects of ASD and can be used in conjunction with ABA therapies, but they would not be effective as stand-alone interventions.
Another intervention is the psychopharmacological intervention for ASD. While there is no cure for ASD, there are common features of associated with ASD, that can be treated with medicine.
Medicines can be use to treat some of these disorders common with ASD include:
seizure disorders
attention deficit hyperactivity disorder
depression
sleep disturbances
behavioral disorders
Medications that have been approved for irritability and aggression are Risperidone (ages 5 and up) and Aripiprazole (ages 6 and up).

Side effects for atypical antipsychotics include:
weight gain
sedation
elevated triglycerides
insulin resistance
elevated prolactin (especially risperidone)
prolonged QTc interval
ADHD symptoms can be managed through the use of several medications.

Methylphenidates (ages 6 and up) include:
Ritalin and Ritalan SR
Concerta
Methylin
Metadate
Daytrona
Ampetamine/Dextroamphetamine (ages 3 and up):
Adderall
Dexedrine
Dexrostat
Lisdexamfetamin (ages 6 and up):
Vyvanse
Adverse side effects for stimulants:
decreased appetite
disturbed sleep
increased anxiety
irritability and aggression

When using stimulants, other factors should be taken into account, such as:
short acting forms have stronger peak effects and stronger rebounds
long acting forms can be better tolerated
when changes in stimulant medications need to take place, it is generally better to change to a different active agent
Murry, M., Penn State
Murry, M., Penn State
Autism Speaks
Autism Speaks
Alpha Agonists for ADHD Symptoms
Clonidine
Guanfacine
These can be used alone or with a stimulant

Effective for impulsivity and motor overactivity

Adverse effects:
orthostatic hypotension
mood irritability
fatigue
Murray, M., Penn State
Selective Serotonin Reuptake Inhibiters (SSRI).
Approved for youth for treatments of depression, anxiety, and OCD:
Lexapro (12 and up)
Prozac (8 and up)
Luvox (8 and up)
Zoloft (6 and up)
Murray, M., Penn State
Autism Speaks
Autism Speaks
Autism Speaks
Teachers should know that if a students is given an SSRI, it generally takes 4-6 weeks to measure its efficacy before considering if more dosage is needed. Telling the parents that the medication is not working, would not be appropriate.

Teachers should also note what the adverse reactions could be:
insomnia
GI distress
behavior disinhibition
Of a serious note of matter is that the FDA issued a "black box label" on all antidepressants for children and young adults (up to 25) warning that the patients be closely monitored for worsening symptoms of depression and suicidal thoughts.
Sleep with ASD children differs in delayed sleep, briefer REM periods and decreased stage 3 and 4 sleep. Medications helpful for sleep are:
Trazadone
Mirtazapine
Clonidine
Melatonin
Murray, M., Penn State
Murray, M., Penn State
There are three major classes of drugs in consideration for treatment of ASD.
They are selective serotonin reuptake inhibitors (NIMH, 2013) psychostimulants, typical antipsychotics, typical and atypical, (Blankenship, Erickson, Stigler et al., 2011) and although there are divers of medications that are being prescribed for ASD, they are being prescribed off-label. An off-label designation means that U.S. Food and Drug Administration (FDA) have not approved them in the treatment of autism. This does not necessarily mean that the drugs are not effective, it means that more research is needed to determine if the medications are safe and effective in treating children with ASD.

There are many interventions that can be used for ASD and symptoms of ASD. They will be further discussed this afternoon.
One of the interventions that will be discussed now is the use of Augmentative and Alternative Communication (AAC). AAC's are not stand-alone intervention, while some of the interventions that will be further discussed are.
Regardless of the students' language ability, AAC's can range from helpful to necessary. AAC's can range from high-tech to low-tech. The goal is to help students be able to communicate and express themselves through the use of the AAC.
Can all of my students use AAC's?
There are two types of AAC's, aided and unaided AAC's.
Unaided AAC's rely on the users body to convey messages. Aided AAC's require the use of tools, plus the person's body to communicate.
Social Deficits?
Lewis, M. et al
Some devices require the user to spell words and other devices use pictorial representatives for words, or the word spelled out. They can even be programmed to include words and names most often used by the student. Dynamic displays change between functions, but static displays remain the same.
Examples of low-tech Picture Exchange Systems for the classroom.
No-Tech ACC
Examples of no-tech AAC is using signs for communication. This can include sign language or even blinking with eyes.
Mid-tech AAC's generally have a static design (the same set of words programmed) and they generate speech according to which picture symbol is pushed.
High-tech options can be very expensive, but very versatile in use. Usually more training is necessary for use. They perform as a computer system and the voice output design is more sophisticated and can even have word prediction.
AAC's are intended to enhance existing functional communication by:
1) Clarifying vocalizations, gestures, body language, etc.
2) Expanding the language of limited speakers by increasing their vocabulary to include verbs, descriptors, exclamatory comments, etc.
3) Replacing speech for people who are nonverbal;
4) Providing the structures and tools to develop language.

Do you think that the use of AAC's hinder communication growth?

No, in fact, research shows that AAC's facilitate growth in language skills.
Califero, J., Meaningful Exchanges for People with Autism
Califero, J., Meaningful Exchanges for People with Autism
Califero, J., Meaningful Exchanges for People with Autism
Califero, J., Meaningful Exchanges for People with Autism
ACC's
Interventions
Seeking effective interventions for ASD students takes a interdisciplinary approach in finding what is most effective for the student in being successful at school, and at home. As you can see, there are many options for our students. Each plan should be individualized and appropriate for each student.
The Fuel (Catalyst) for it all.
The foundations for all of the approaches discussed are based on the successfulness of the students by positive input and positive approaches.
Positive Behavior Supports
Positive behavior supports can help ASD students with problem behaviors. PBS can be implemented with all of the interventions that we have discussed.

ASD students may have difficulty communicating dealing with their environment, as well as communicating their wants and needs. An important part of PBS is figuring out what the function of student's behavior is.
Association for PBS
PBS are effective for ASD students by providing the student direct and indirect instruction ways to replace problem behaviors. PBS can implement changes in the students day to help them be successful. This would include changing routines, situations, and settings so that the students can avoid the situations that trigger the problem behaviors.
APBS
You should know that PBS is not new. Like we talked about, it is based on the science of Applied Behavior Analysis. PBS in not one program or specific strategy. As teachers, it's important to remember that sometimes even the best plans will not work at all times. This is why it is important to have a variety of supports.
PBS:
prevent challenging behaviors
teach new skills
use team approach


One model of PBS is
Antecedent Based Interventions
Uses a variety of strategies:
preferred interests, activities, items to increase interest/motivation and manage behavior
embed in schedule
use in curriculum
reinforcement
change/alter the schedule/routine
visual schedule
adult vs. student directed
preferred vs. non-preferred
Transition interventions
warnings
timers
routines
Choices
Differentiated Instruction
Access to sensory stimuli
Another model is the Prevent Teach Reinforce model. This model uses looks at data and functions for behavior to best prevent behaviors. The model then determines what behaviors need to be taught or retaught to the student/s. And then what reinforcers will best prevent future maladaptive behavior or reinforce future positive behaviors.
Challenging Behaviors.org
All of the PBS models use an Functional Behavior Assessment. The FBA is a foundational component of the FBA. The FBA uses a antecedent, behavior, consequence model.

The team must determine what the function of behavior is by looking at the
Antecedent - where, when, who, demands/expectations, environmental arrangements, instruction/curriculum
Behavior - what happens during the occurance
Consequence - what happens after
By looking at the FBA, the team can determine the function of the behavior.

Is it to get/avoid something
Is it a skill deficit
Is it performance deficit
ASD symptoms of rigidity/routines, lack of generalization/over generalization
Giving students Positive Behavior Supports focus both on prevention of problem behaviors and give early access to effective behavior support. Also, just as importantly, they are culturally competent and are family-friendly behavior supports.
Implementation of PBS of sufficient intensity and precision can produce behavioral gains that have a significant and durable impact on the academic, social and living options available to the student.

NASP Online
Today we have learned much about what is best for our ASD learners. Many aspects you are already implementing well. New components you have learned today will be implemented through your Special Education team, along with your LSSP. Please contact the team leader for more information.
Specific Changes from DSM IV to DSM V
Using DSM-IV, patients could be diagnosed with four separate disorders: autistic disorder, Asperger’s disorder, childhood disintegrative disorder, or the catch-all diagnosis of pervasive developmental dis- order not otherwise specified. Researchers found that these separate diagnoses were not consistently applied across different clinics and treatment centers.



Facts from CDC-

Boys were almost 5 times more likely to be identified with ASD than girls. About 1 in 42 boys and 1 in 189 girls were identified with ASD.
White children were more likely to be identified with ASD than black or Hispanic children. About 1 in 63 white children, 1 in 81 black children, and 1 in 93 Hispanic children were identified with ASD.
Almost half (46%) of children identified with ASD had average or above average intellectual ability (IQ > 85).
Less than half (44%) of children identified with ASD were evaluated for developmental concerns by the time they were 3 years old.
On average, children identified with ASD were not diagnosed until after age 4, even though children can be diagnosed as early as age 2.
About 80% of children identified with ASD either had a special education eligibility for autism at school or had an ASD diagnosis from a clinician. This means that about 20% of children identified with ASD had documented symptoms of ASD in their records, but had not yet been classified as having ASD by a community professional.
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