communication supports and - apbs · communication supports and ... nouns, visual symbols can be...

©Pat Mirenda, Ph.D., 3/08 1

Augmentative and AlternativeCommunication Supports for Problem

Behavior in Individuals with Autism

Association for Positive Behavior SupportChicago, IL March 29, 2008

Pat Mirenda, Ph.D.University of British Columbia

([email protected])

Communication Supports andPBS: Why? There is a clear relationship between

problem behavior and communication people communicate in the most efficient and

effective manner available to them at anygiven point in time

Some people have no way tocommunicate except through problembehavior individuals with limited or no functional speech

who use augmentative and alternativecommunication (AAC)

Communication Supports andPBS: Why? Some people have other ways to communicate,

but don’t know how or are unable to access thoseother ways in some situations individuals whose problem behavior is triggered by

situations that are frustrating, stressful, or anxiety-provoking

Some people have other ways to communicate,but no one really "listens" until they use problembehavior individuals whose usual communication behaviors are

subtle or otherwise difficult to interpret


Communication Supports andPBS: Who? Individuals with or without speech who

have difficulty communicating and engagein problem behavior

Today’s focus: individuals with autism whoare unable to speak and use (or need touse) AAC Communication challenges are part of the

core disability

Communication Supports andPBS: What?

Augmented input supports to aidcomprehension Visual schedules Visual contingency maps and wait signals

Augmented output supports to aidexpression Augmented choice making Functional communication training

Symbol Assessment Research suggests that, at least for

nouns, visual symbols can be arranged inan easy-to-hard hierarchy of learning,based on their similarity to a referent (seeHurlbut, Iwata, & Green, 1982; Mirenda &Locke, 1989)


In general, the hierarchy is as follows: Objects (identical/non-identical) Color photos Black & white photos Line drawing symbols (e.g., Picture

Communication Symbols) Blissymbols Printed words

Symbol Hierarchy

+!friend

juice

Symbol Assessment Question: what type(s) of symbol will this person learn

to recognize most easily? Interviews

“Does Jane recognize logos of favourite foods,places?” (e.g., Coke, the Golden Arches)

“Does Jane recognize pictures if you namethem?”

“What type(s) of symbol has Jane usedsuccessfully in the past?”

Observations Observe with books, print, reactions to pictures

and logos Direct assessment:

Symbol Assessment “Kit”

Collect objects (10-15) with which theperson is familiar; ask the family to makesure

Assemble sets of symbols correspondingto the objects

Examples:


Symbol Assessment Formats Two primary assessment formats:

Receptive labeling Visual matching

Franklin, Phillips, & Mirenda (1994): Similar results for both formats with

typical 2- and 3-year-old children andstudents with severe disabilities in thesame developmental age range

Receptive Language Format

Two or more objects or symbols arepresented to the student

Assessor asks “"Give me/point to/look at X."

“Give me the shoe”

Visual Matching Format One object is presented to the student Assessor places two symbols on the

table, one of which corresponds to theobject, and asks the student to “find thesame/match it/give me one like this”

“Match it”


Symbol Assessment

Ideally, repeat the symbol assessmentover more than one day, in differentcontexts (e.g., busy/noisy, calm/quiet)

The highest order symbol with which theperson is successful at ≥80% accuracyis typically selected for intervention See Beukelman & Mirenda (2005) for

extended symbol assessment formats

Visual Schedules Used to organize sequences of time or steps in

a task Real objects, photographs, picture symbols (like

Picture Communication Symbols, PCS), orwritten words can be used to represent theactivities or environments

VERY useful for transitions betweenenvironments and/or activities for manyindividuals (Bopp, Brown, & Mirenda, 2004)

Visual Schedule Research(Bopp et al., 2004) Visual schedules have been used successfully:

With individuals with ASD across a range of ages(from 29 months to 17 yrs)

Across a variety of settings (including segregated andregular classrooms, family homes, and communitysettings)

To address a variety of problem behaviors (includingoff-task behavior, disruptive behavior, non-compliance, aggression, tantrums, and propertydestruction)

In a variety of formats (e.g., a small photo album withcolor photographs, line drawings arranged verticallyon a single page, etc.)


Computer-Enhanced ActivitySchedules Take advantage of multimedia options

available in Powerpoint® and otherauthoring tools

Can add Digital photographs Digital video clips Voice narration and other sounds Automatic timing

Research Robert Stromer, Elisabeth Kinney, and colleagues in

New England have done several studies usingcomputer-enhanced activity schedules with children withautism to teach: Independent activity sequences (Stromer, Kimball, Kinney, &

Taylor, 2006) Social skills (Kimball, Kinney, Taylor, & Stromer, 2004) Sociodramatic (pretend) play (Dauphin, Kinney, & Stromer, 2004) Generative spelling (Kinney, Vedora, & Stromer, 2003) Money and number skills (Stromer et al. 2006)

See Rehfeldt, Kinney, Root, & Stromer, 2004 andKimball, Kinney, Taylor, & Stromer, 2003 for “how to”directions using Powerpoint®

Contingency Maps Goal: to provide information about the

“current” (i.e., problem) and “desired”behavioral pathways related to problembehavior Hopefully, this information will help the

individual understand why he or she shouldengage in the behaviors associated with the“desired” pathway!


Contingency Map A contingency map depicts

The antecedent that typically triggers a problembehavior

The problem behavior The consequences that will follow if it occurs

Ideally, the natural consequences; if not, artificial A functionally-related (desired) alternative

behavior The consequences that will follow if it occurs

Again, ideally, the natural consequences

Del (Brown, 2004)

6-year-old boy with autism, good verbal skills,high need for predictability and order

PBs: screaming, crying yelling, self-injuriousbehavior

Triggers: paper-and-pencil tasks in grade 1(fine motor difficulty) and PE class onThursdays in the gym (unpredictable, chaotic)

Function: escape from difficult activities Impact: Del was socially isolated from his

classmates because they were afraid of him

Intervention Paper-and-pencil task: teach Del to ask for a

short break, as needed PE class: teach Del to ask the teacher for

permission to sit and watch the class instead ofparticipating, as needed

Verbal explanations given regarding the new,“desired” behaviors before each relevant activity

No changes in Del’s behavior


Contingency Map

Contingency Map: PE

Result Immediate and dramatic reduction in Del’s

problem behavior as he began to use thenew, desired behaviors

Lasted throughout grade 1 and into grade 2 Del received the most votes when the class

was asked to choose who they wanted to sitnext to for a new seating plan


Kirk (Brown & Mirenda, 2006) 13-year old boy with autism Included in a regular grade 6-7 classroom, with

modified curriculum; supported by an educationalassistant (EA)

PB: extreme prompt dependency for many yearsthat was getting worse over time In class, Kirk sat and waited idly until the EA noticed

that he finished his work; wasted a lot of time! Desired behavior: getting up from the desk,

walking to the EA with finished work, and saying“I’m finished”

Intervention Three contingency maps were created for keyboarding,

math, and printing All three were identical except for the antecedents Natural consequence for prompt dependent behavior

was that Kirk would sit and get no work done -- couldn’tbe used!

Artificial consequences used instead: Prompt dependent behavior = no “treat” Alternative behavior within 3 min of task completion = choice of

preferred treat (choice of sugarless chocolate, cracker,broccoli, apple juice)

Keyboarding Map


InterventionABCD multiple baseline design across

activitiesA: baseline (no intervention)B: verbal explanations ofcontingencies

C: verbal explanations + contingencymaps (left on Kirk’s desk)

D: follow-up 1 and 2 weeks post-intervention

Results

AntoniaGrade 2 student with autism, little speech Included for half of the day; remainder in

resource room because of problem behaviorProblem behaviors: head-butting, hitting, and

pinching classmates and adults when she hadto wait

For her turn during buddy readingIn lineFor the computer to boot up, etc.Waiting was also an enormous problem at home


Wait Signal Antonia’s speech-language pathologist,

Vicki, decided to teach her to wait, using a“wait symbol” (a red circle that symbolized“wait”)

Vicki provided systematic instruction in asimulated “buddy reading” activity to teachher the meaning of the red circle: “you willget what you want, but not quite yet…”

Generalization Once Antonia learned what the wait signal

meant in buddy reading, contingencymaps were created to help her generalizethis understanding to other situations atschool and at home….

Contingency Map: Waiting in Line


Contingency Map: Computer

Augmented Choicemaking

Augmented input provide visual supports to clarify what

choices are available Augmented output

provide symbols or other techniques toenable the person to make choices

Matt (Mirenda, 2004)

19 years old, lived at home at beginning ofintervention, integrated in regular high schoolclasses with support

Some speech (1-2 word phrases) but not whenstressed

Behavior: severe aggressive outbursts towardfamily, support staff over several years at least one episode per week serious enough

to cause bruising


Assessment

Functional assessment to determine thefunctions of the behavior tangibles: “I want ----”: Matt wanted

something (food, activity) and had no way toask for it; aggression led to “20 questions”

escape: “I don’t want ----”: Matt was offered afood or activity and did not want it

escape: “I don’t understand”: the schedule ofactivities was unpredictable

Intervention

Picture Communication Symbols were provided to clarify what choices were available enable Matt to initiate and make choices, and

thereby reduce the frequency of having to tellhim what would happen next

Within- and between-task visual schedules werealso provided to increase predictability

FCT/AAC Functional communication training (FCT)

involves “both the assessment of thefunction of the challenging behavior andthe teaching of a more appropriate formthat serves the same function . . .”(Durand, 1990, p. 23)

FCT/AAC interventions are those in whichthe “more appropriate form” involves AAC(Mirenda, 1997)


Ron (Durand, 1999)

Age 9 1/2, had autism and “severemental retardation”

Spoke a few words, out-of-context Very aggressive; hit teachers, other

students, family members Variety of other interventions had failed

(DRO, DRI, time-out, restraint, etc.)

Assessment Functional assessment conducted to

identify function of problem behaviors Appeared to be attention-motivated --

Ron engaged in the behaviour to getattention from his teacher or other adults

Intervention Provided with a SGD (BIGmack) that

was programmed to make a request thatwould result in attention:

Would you help mewith this, please?


Instruction Instruction provided during regular

classroom routines that were appropriateto the message being taught graduated guidance prompts and fading used

to teach brief attention (in the form of “help”) was

provided when communication device wasactivated

Results

Generalization Ron was regularly taken to a book and

magazine shop as part of his IEP (heenjoyed these materials) baseline data obtained on how often he

attempted to get attention from others;attempts toward aggression were blocked

following FCT instruction, provided withBIGmack in store so he could ask clerk orothers “Would you help me with this?”


Results

Key Requirements for FCT/AAC Identify the specific function of the

problem behavior Tangible: “I want item/activity” Attention: “I want social interaction” Escape: “I don’t want item/activity/person” Sensory: “I’m bored/or stimulated”

How? Functional behavior assessment(e.g., O’Neill et al., 1997)

Key Requirements Identify a related “message” that will be

acceptable to the people and in thecontexts where it will be used e.g., “Pay attention to me” vs “Would you

help me with this?” vs. “Can I help you?” vs“Am I doing good work?” for attention-motivated behavior

How? Input from and negotiation withparents, teachers, etc. in the settingswhere the behavior occurs


Key Requirements Identify an AAC technique that will

enable the person to communicate the“message” to both familiar andunfamiliar partners Manual sign/gesture Object/picture symbol Written word

How? Symbol assessment, input fromspeech-language pathologist

Key Requirements Teach use of the new communicative

behavior in context Look for “whispers” of the problem

behavior Provide “clean” instruction before the

problem behavior occurs Be sure the new behavior results in the

same (desired) consequence!

Paula, Peter, and Mary(Hunt, Alwell, & Goetz, 1988; 1990)

3 adolescents with disabilities in integratedsecondary schools

All exhibited “silly” behaviours Paula:

giggling making silly noises ducking head, grimacing


Paula, Peter, and Mary (Con’t)

Peter: grabbing other

people’s hands calling names of

absent people repeating peoples’

names etc.

Mary: talking to imaginary

other people imitating animals getting on furniture lying on floor leaving the classroom

Assessment Observations, interviews of staff and peers

at school FBA indicated that behaviours were

primarily social interaction-motivated,directed mostly at nondisabled peers

The “message of the behaviour was: “I want to interact with you/Pay attention

to me”

Intervention Provided students with “conversation

books” to facilitate appropriate socialinteraction use activity remnants, photographs of

students in favourite activities, etc. include written captions with comments

and questions “Here I am with my dog, Sharma. Do you have

a dog?” “This is me at my 16th birthday party. When is

your birthday?”


Conversation Book (Con’t)

update bookregularly, so topicsare dynamic

be sure book isportable, so that itcan be carried aroundeasily

Conversation Book (Con’t)

Teach use of conversation books short (2-5 min.) teaching sessions natural settings for conversation use student, partner, and coach provide partner with basic information

Prompt responses, comments, AND questions Teach turn-taking during conversations Teach “fillers” (uh-huh, yeah, etc.) Don’t be rigid with the structure

Results


Punchline AAC interventions play a key role in

interventions for problem behavior Need to base communication supports on

information from functional behaviorassessment

Need to individualize for easy access andminimal learning

ReferencesBambara, L., & Kern, K. (2005). Individualized supports for students with problem behaviors. NY: Guilford.Bopp, K., Brown, K., & Mirenda, P. (2004). Speech-language pathologists’ roles in the delivery of positive

behavior support for individuals with developmental disabilities. American Journal of Speech-LanguagePathology, 13, 5-19.

Brown, K. (2004). Effectiveness of functional equivalence training plus contingency mapping with a childwith autism. Unpublished masters thesis, University of British Columbia.

Brown, K., & Mirenda, P. (in press). Contingency mapping: Use of a novel visual support strategy as anadjunct to functional equivalence training. Journal of Positive Behavior Interventions.

Carr, E., Levin, L., McConnachie, G., Carlson, J., Kemp, D., & Smith, C. (1994). Communication-basedintervention for problem behavior. Baltimore: Paul H. Brookes. (http://www.pbrookes.com/)

Clarke, S., Dunlap, G., & Vaughn, B. (1999). Family-centered, assessment-based intervention to improvebehavior during an early morning routine. Journal of Positive Behavior Interventions, 1, 235-241.

Durand, M. (1999). Functional communication training using assistive devices: Recruiting naturalcommunities of reinforcement. Journal of Applied Behavior Analysis, 32, 247-267.

Journal of Positive Behavior Interventions, Published by PRO-Ed, http://www.proedinc.com/Luiselli, J., & Cameron, M. (1999). Antecedent control. Baltimore: Paul H. Brookes.Mirenda, P. (1997). Functional communication training and augmentative communication: A research

review. Augmentative and Alternative Communication, 13, 207-225.

Mirenda, P. (2001). Autism, augmentative communication, and assistive technology: Whatdo we really know? Focus on Autism and Other Developmental Disabilities, 16, 141-151.

Mirenda, P. (2003). Toward functional augmentative and alternative communication forstudents with autism: Manual signs, graphic symbols, and voice output communicationaids. Language, Speech, and Hearing Services in Schools, 34, 202-215.

Mirenda, P. (2003). Using AAC to replace problem behavior. Augmentative CommunicationNews, 15 (4), 10-11.

Mirenda, P., MacGregor, T., & Kelly-Keough, S. (2002). Teaching communication skills forbehavior support in the context of family life. In J. Lucyshyn, G. Dunlap, & R. Albin(Eds.), Families and positive behavior support: Addressing the challenge of problembehaviors in family contexts (pp. 185-207). Baltimore: Paul H. Brookes.

O'Neill, R., Horner, R., Albin, R., Sprague, J., Storey, K., & Newton, S. (1997). Functionalassessment and program development for problem behavior. Pacific Grove, CA:Brooks/Cole.

Reichle, J., Beukelman, D., & Light, J. (2002). Exemplary practices for beginningcommunicators. Baltimore: Paul H. Brookes.

Scotti, J., & Meyer, L. (1999). Behavioral intervention: Principles, models, and practices.Baltimore: Paul H. Brookes.

References (Con’t)

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