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Post on 18-Oct-2014
Early Intervention for Toddlers with Autism Spectrum DisordersIs It a Special Case?Hannah Schertz, Ph.D.
Get a reading from audience on backgrounds1Autism Spectrum Disorders (ASD)Social communication disorder with repetitive or stereotypical behavior and/or fixed interestsWide-ranging in severity4-5 times more prevalent in boys than girlsPrevalence in 8-year-olds is nearly 1:100 http://www.cdc.gov/ncbddd/autism/data.html#prevalence Increase due to broader diagnostic criteria, awareness, improved screening and diagnosis
(Odom, Schertz, Wong, in press)Background facts
2ASD in ToddlersAllDifficulty with preverbal social communicationLooking at others facesReciprocal back-and-forth interaction with a partnerSharing attention about mutual interestsSome Fixed or repetitive interests and behaviors (may not appear until later)Challenging behaviors related to communication difficulties and/or fixed interests
(Boyd, Odom, Humphreys, & Sam, 2010)ASD is characterized by*:Difficulty with social communicationNonverbal and verbalLack of social reciprocityDifficulty with peer relations appropriate to developmental levelFixed or repetitive interests and behaviorsStereotyped motor or verbal behavior, or unusual sensory reactionsExcessive adherence to routines and ritualized patterns of behaviorRestricted, fixated interests
Symptoms are present in early childhood but may not be fully manifest until social demands become important. Aspergers would no longer be considered a separate disorder
Video examples:Andrew behavior: Note uses mom as an instrument; his interest is in the object, not momConnor aggression: repetitive behavior
3CausesGenetic influenceConnected to vaccines? Disproved in multiple studiesBrain differences: Effect or cause?Genetic influence (twin and sibling studies)No proven relationship between ASD and vaccines in numerous studies. An article claiming a relationship was later refuted by the publisher. Neurological studies show structural and functional brain differences, but not determined to be a cause (could be either a cause or effect of ASD).
Implications of fear of vaccines (four-fold increase in pertussus in CA)4Early IdentificationWhy is it important?Improved outcomes with early intervention Early support and education for parentsListen 5Early IdentificationHow can early educators help? Know red flagsListen and respond to parents concernsProvide prompt access to screening and diagnostic evaluation Be vigilantRed flags for toddlers Not showing objects or following pointsNo pretend play by 18 monthsAvoiding looks to others facesRepeating actions over and over Difficulty adjusting to new routineshttp://firstsigns.org/ http://firstwords.fsu.edu/ http://www.ddhealthinfo.org/documents/ASDquickguide.pdfThis is a partial list. See websites for more detail
Show video exemplifying red flags7Communicating with FamiliesResponding to family suspicion of ASDTake seriously: Parents often raise first concern; want prompt answersFacilitate screeningRefer for diagnostic evaluation if screen shows high riskAvoid suggesting ASD before diagnosisCommunicating with FamiliesIf you have concerns before the family does:Offer screening to all familiesAvoid using autism terminology Avoid writing off reticence as denialKeep in touch for support and follow-up Proceed on parents terms when ready.Do not wait for diagnosis to address social communication needs Offer screening to all families; have diagnostic services lined up in advanceTalk about social communication, not ASDAvoid using autism terminologyAvoid writing off reticence as denialKeep in close contact for support and follow-through. Parents will have support needs regardless of readiness to proceed with identificationProceed on parents terms and only when ready.Do not wait for diagnosis to address social communication needs
9ScreeningModified Checklist for Autism in Toddlers (MCHAT; Robins, Fein, Barton, & Green, 2001): Free parent questionnaire & instructionshttp://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D..htmlWho can administer? Parent completedSimple scoring proceduresFollow-up interview for greater reliability
Difference between screening and diagnostic assessment? Modified Checklist for Autism in Toddlers (MCHAT; Robins, Fein, Barton, & Green, 2001), not the less reliable CHAT Free parent questionnaire with scoring instructions available at http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D..htmlWho can administer the M-CHAT? No special qualifications required (parent completed). Simple scoring proceduresFollow-up interviewReview it10Evidence-based InterventionApproaches reported for toddlers with ASDTraditional behavioralNaturalistic behavioralDevelopmental
Approaches Refer to research brief on ITSI website
Approaches reported for toddlersTraditional behavioral: ABC; Discrete Trial Training; adult-centeredNaturalistic behavioral: more child centered; more likely to occur in the natural environmentDevelopmental: Considers typical development sequences; socially embedded; integrated across domains
Models for older children (3-5) may be pushed down for toddlers. Why is this a problem?
Intensive (per National Research Council)
Question: What implications do each of these approaches have for intensity? Would similar intensity levels be likely to be used with traditional behavioral and developmental models?
For a broad-based treatment of issues in determining EBP in early childhood, see Buysse, V., & Wesley, P. W. (Eds.; 2006). Evidence-based practice in the early childhood field. Washington, D.C.: Zero to Three.
11Evidence-based InterventionConsider each approach for:Intensity: Implications for eachEffectiveness : The big picture, not just narrow skills (Buysse & Wesley, 2006) Outcomes: Socially grounded, meaningful in everyday life, developmentally appropriateProcess : How it fits with principles of practice for toddlers and families values/priorities Mary McMullens essay?
Implications for intensity requiredEffectiveness: Consider big picture (Buysse & Wesley, 2006), not just narrow skills Outcomes: Socially grounded, meaningful in everyday life, developmentally appropriateProcess : How it fits with principles of practice for toddlers and families values/priorities (childs needs are not viewed in isolation of the family unit)
12Traditional BehavioralLovaas: Traditional Applied Behavioral Analysis (ABA); Discrete Trial TrainingLearning theory: Modify what comes before or after to elicit, change, eliminate behaviors Adult directed (; prescribed learning tasks)Intensive (35-40 h/w)Prompting, reinforcement, fading, time-delayResearch counters unqualified effectiveness claimsIn widespread useMention Mary McMullens critique13Naturalistic BehavioralSimilar to traditional behavioral view that children learn by modifying behaviors in response to environmental contingenciesConsiders child interests & motives (more child centered); natural reinforcersGaining ground over traditional ABAExamples: Pivotal response treatment (emphasizes behaviors important for broader learning); incidental teachingAssumptions about how children learn (e.g., reinforcement) are similar to traditional behavioral approachesConsider childs interests or motives (more child centered); natural reinforcersGaining ground over traditional ABAExamples: Pivotal response treatment (emphasizes behaviors important for broader learning); incidental teaching
14DevelopmentalChild brings internal competency to learningAdults follow childs lead to promote spontaneity, initiative, & self-directed learning Promotes internal motivation, natural consequencesEmphasizes social relationships, affect sharingExamples: Developmental Social Pragmatic, Joint Attention Mediated Learning (JAML), Early Start Denver Model (hybrid)15Early Intervention: Core PrinciplesFamily-centered and strengths-based Natural and inclusive environmentsDevelopmentally soundActive and functional child engagementCoordinated and systematic
Schertz, H. H. (in press)16Intervention for Toddlers with ASDObserving practices for toddlers with ASD:How do current practices fit with each principle?How can we reconcile differences or make changes when there is not a fit? Observing practices for toddlers with ASD:How do current practices fit with each principle?How can we reconcile differences or make changes when there is not a fit? Change the intervention approachAlter practices within the approach 17Principle 1: Family-centered & Strengths-basedFamily-centeredIncorporates family prioritiesSupports parent-child relationship rather than replacing it with professional-child interactionStrengths-basedViews families as capable Enables (rather than trains) families to promote toddler social developmentReturn to the slides on approaches and have them make notes on issues for each18Principle 1: Family-centered & Strengths-based Which best promotes an active family role? Child participates in prescribed, highly structured intervention Train parents in specific behavioral strategies Support families to use their knowledge of the child to embed learning throughout everyday activitiesPrinciple 2: Natural & Inclusive EnvironmentsPart C requirementGroups mirror the general population in proportion of children with disabilitiesBenefits It is where most learning occursFacilitates natural family roleEmbeds learning in natural everyday activities with familiar peopleNaturally facilitates generalization of learning Not half and half or a few typically developing peers20Principle 2: Natural & Inclusive EnvironmentsWhich best promotes learning that is meaningful in the everyday world? Clinic-based or segregated settingsProfessionally implemented in natural settings with expectation that learning will carry overNatural settings with learning embedded into natural activities with familiar peoplePrinciple 3: Developmentally Sound InterventionFollow natural developmental sequencesAddress preverbal social communication firstBuild on natural precursors Motivate, prevent behavior challenges with:Developmentally appropriate activitiesActivities that match development & interestsRespect for childs tolerance levelFocus on what underlies behavioral challenges rather than just reacting to them
22Principle 3: Developmentally Sound InterventionWhich belief(s) about learning challenge the child just above current skill levels?Learning occurs by modifying behaviorsLearning occurs by modifying behaviors with consideration for child interestsLearning builds on current competencies; considers foundational competencies that can take child to a new levelPrinciple 4: Active, Functional Child EngagementSocial communication is more than a collection of isolated skillsFollow childs lead rather than prescribing highly structured activities & materialsEncourage child initiative, not just respondingAvoid dependency on external rewardsPromoting foundational competencies helps children learn on their own Principle 4: Active, Functional Child EngagementWhich promote(s) meaningful engagement?Activities selected & directed by adults with structured protocols; child engagement is maintained through reinforcersActivities incorporate child interests, create opportunities for natural reinforcersActivities follow childs lead; goals promote meaningful social engagement in everyday interactions; passive responding is less valued
Principle 5: Coordinated & SystematicTeam members provide systematic background support rather than side-by-side servicesGuidelines for developmental approaches: Intervene in the zone of proximal developmentEmbed learning within meaningful social contexts Scaffold learning Mediate learning (planfully) rather than trainGuidelines for behavioral approaches: Promote pivotal (foundational) learningUse tested strategies; follow child interestsAvoid focus on narrow skills with limited relevance to everyday life or to meaningful future goalsSupport generalization by working in natural environmentsVideo example of intervention in action. Child showing IJA (dad)
26Principle 5: Coordinated & SystematicWhich are coordinated & systematic?Specialists organize services around areas of delay; team defers decisions to specialists; may be intrusive, inefficient, and at cross purposesTeam members (including parents) share expertise, encouraging others to consider their goals. Team members systematically support each others learning, fading support as expertise is gainedOutcomes and intervention processes are planned and delivered systematically considering evidence of effectiveness and developmental researchIs toddler intervention in ASD a special case? Yes Focus on preverbal social communicationNoToddlers with ASD are children firstPrinciples of good early intervention apply28Online ResourcesAssociation for Science in Autism Treatment http://www.asatonline.org/ Autism Society of America http://www.autism-society.org/site/PageServerAutism Speaks. http://www.autismspeaks.org/Centers for Disease Control: Autism Spectrum Disorders (ASDs) http://www.cdc.gov/ncbddd/autism/index.htmlIndiana Resource Center for Autism (IRCA). http://www.iidc.indiana.edu/irca/ National Early Childhood Technical Assistance Center (NECTAC): Autism spectrum disorders. http://www.nectac.org/topics/autism/autism.aspNational Research Council (2001). Educating children with autism. http://www.nap.edu/openbook.php?isbn=0309072697
ReferencesBoyd, B. A., Odom, S. L., Humphrey, B. P., & Sam, A. M. (2010). Infants and toddlers with autism spectrum disorder: Early identification and early intervention, Journal of Early Intervention, 32(2), 75-98.Buysse, V., & Wesley, P. W. (Eds.; 2006). Evidence-based practice in the early childhood field. Washington, D.C.: Zero to Three.Odom, S. L., Schertz, H. H., & Wong, C. (in press). Autism spectrum disorders in young children. In H. H. Schertz, C. Wong, & S. L. Odom (Eds.). Young Exceptional Children Monograph 12: Supporting Young Children with Autism and Their Families. Missoula, MT: Division for Early Childhood.Robins, D. L., Fein, D., Barton, M.L., Green, J.A. (2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31, 131-144.Schertz, H. H. (in press). Principles of intervention for young children: Implications for toddlers and preschoolers with autism spectrum disorders. In H. H. Schertz, C. Wong, & S. L. Odom (Eds.). Young Exceptional Children Monograph 12: Supporting Young Children with Autism and Their Families. Missoula, MT: Division for Early Childhood.