Doreen Granpeesheh, Ph.D., B.C.B.A-D

Report
Autism Spectrum
Disorders:
Research findings and
treatment implications
Doreen Granpeesheh, Ph.D. B.C.B.A-D
Center for Autism and Related Disorders, Inc
Today’s Presentations
DSM 5 diagnosis of ASD
A multi-disciplinary treatment model
What is ABA (Applied Behavior Analysis)
Applications of behavior analysis to the
treatment of ASD
Autism Spectrum Disorder
Doreen Granpeesheh, PhD,
BCBA-D
DSM IV
Autistic Disorder: Total of 6 or more symptoms < age 3
 Social Deficits (2)
• Eye Contact
• Showing/Sharing
• Emotional Reciprocity
 Communication Deficits
• Language
• Pretend Play
• Conversation
 Stereotypic/Repetitive Behaviors
•
•
•
•
Routines
Preoccupation
Intense focus
Motor
4
DSM IV
Asperger’s
 Social Deficits: 2
 Stereotypic/Repetitive: 1
 No Communication Deficit
PDDNOS
 Same as Autistic Disorder but less than 6
symptoms
5
Autism Spectrum Disorder: DSM-5
Criterion A: Persistent deficits in social communication and social interaction
across contexts, not accounted for by general developmental delays, and
manifested by all 3 of the following:
1. Deficits in social-emotional reciprocity; ranging from abnormal social
approach and failure of normal back and forth conversation through
reduced sharing of interests, emotions, and affect and response to total lack
of initiation of social interaction,
2. Deficits in non-verbal communicative behaviors used for social
interaction; ranging from poorly integrated verbal and nonverbal
communication, through abnormalities in eye contact and body-language,
or deficits in understanding and use of nonverbal communication, to total
lack of facial expression or gestures
3. Deficits in developing and maintaining relationships, appropriate to
developmental level (beyond those with caregivers); ranging from
difficulties adjusting behavior to suit different social contexts through
difficulties in sharing imaginative play and in making friends to an
apparent absence of interest in people
Autism Spectrum Disorder: DSM-5
Criterion B: Restricted, repetitive patterns of behavior, interests, or activities
as manifested by at least two of the following:
1. Stereotyped or repetitive speech, motor movements, or use of objects;
(such as simple motor stereotypies, echolalia, repetitive use of objects, or
idiosyncratic phrases)
2. Excessive adherence to routines, ritualized patterns of verbal or
nonverbal behavior, or excessive resistance to change; (such as motoric
rituals, insistence on same route or food, repetitive questioning or
extreme distress at small changes).
3. Highly restricted, fixated interests that are abnormal in intensity or focus;
(such as strong attachment to or preoccupation with unusual objects,
excessively circumscribed or perseverative interests).
4. 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) (APA,
2011)
7
Autism Spectrum Disorder: DSM-5
Criterion C: Symptoms must be present in
early childhood (but may not become fully
manifest until social demands exceed
limited capacities)
Criterion D: Symptoms together limit and
impair everyday functioning
8
Key Differences Between DSM-IV-TR
and DSM-5
3 key domains become 2
Shift from categorical to dimensional
Requires 2 repetitive/restrictive behaviors
Language delay is not necessary
Specifiers and modifiers
Level of severity
9
ASD DSM-5 Diagnosis:
Specifiers and Modifiers
With the new criteria, the child will receive
a diagnosis with the etiology as a specifier
 ASD with Rett Syndrome
 ASD with Fragile X
OR with a modifier indicating another
important factor
 ASD with tonic-clonic seizures
 ASD with intellectual disabilities
10
ASD DSM-5 Diagnosis:
Specifiers and Modifiers
Early history is also specified
 Age of perceived onset
 Pattern of onset
• Loss of skills (when?)
 ASD with onset before 20 months and loss of
words
 ASD with onset before 32 months and loss of
social skills
 ASD with no clear onset and no loss
 ASD – Aspergers type
11
Level of Severity
Severity Level for ASD
Social Communication
Restricted interests &
repetitive behaviors
Level 1:
Requiring Support
Without support, some
Significant interference in
significant deficits in social at least one context
communication
Level 2:
Requires substantial
support
Marked deficits with
limited initiations and
reduced or atypical
responses
Obvious to the casual
observer and occur across
contexts
Level 3:
Requires very substantial
support
Minimal social
communication
Marked interference in
daily life
12
Social Communication Disorder
Impaired pragmatic use of language
Difficulty in the social use of verbal or nonverbal
communication
 Must affect development of relationships, comprehension,
academic achievement, or occupational performance
Cannot be explained by low cognitive ability, word
structure, or grammar
Symptoms must be present in early childhood
 But may not fully manifest until social demands exceed capacities
ASD must be ruled out
13
Clinical Implications
ADHD can now be diagnosed along with
ASD
Need to rework assessment measures
 Screeners and gold standard measures of
assessments are based on DSM-IV criteria
Services and third party billing
14
What does ASD look like?
Communication:
 delayed in language
 no eye contact
Social Behavior:
 No interaction with anyone
 Do not play with others
 Do not ask for help
Stereotypy:
 Numerous repetitive behaviors (lining up objects,
opening closing door, turning on and off the lights)
 Many inflexibilities and repetitive routines
Anything else?
Challenging Behaviors!
Sensory Sensitivities!
Medical Illnesses!
AUTISM
Minimize Exposure
Genetic Predisposition
To Toxins
Treat the
Underlying
Medical Disorders
Metals
Pesticides
BisphenolA
Antibiotics
Physical Conditions
Oxidative Stress
Decreased Methylation
Immune Dysfunction GI
Inflammation
Reduce/Eliminate
Symptoms
Identify Sensory
Issues
Teach New Learning
Patterns
Brain Disorders
Hypoperfusion
Hypo and Hyper sensitivity
to stimuli
Different Learning Patterns
Behavioral Symptoms
Delayed Language
Delayed Social Skills
Stereotypy
Minimize Exposure to Toxins
Make sure your physician only uses
antibiotics when necessary
Avoid pesticides (go organic)
Avoid BPA (plastics)
Spread out vaccinations to reduce stress on
immune system
Check for metal toxicity to determine need
for chelation (toxic metal assay)
Treat Underlying Medical Illness
Immune Markers
 Immunoglobulin Subsets (Antibodies that respond to bacteria,
viruses, fungus, etc)
 Check for Strep Titers (PANDAS)
 Vaccine Titers
Detoxification markers
 Redox capacity (Redox SYS™ Diagnostic System).
 Oxidative Stress
 Decreased Methylation/transulfation (fasting plasma
cysteine or methionine markers
Discuss Possible Treatments with your physician
Treat Underlying Medical Illness
Evaluate and Treat GI Disorders
 Nutrition
 Diet
 Medication
•
•
•
•
Anti-inflammatories
Steroids
Anti-fungals
Anti Chlostridia
Help the child become healthy
 Make sure he is sleeping well
 Make sure he is getting the right nutrition
Identify Sensory Issues
Everything we learn enters through our senses
How does your child receive information?
 Does he perceive visual information correctly?
•
•
•
•
Focus versus double vision
Binocularity
Central Vision
Tracking
 Does he perceive auditory information correctly?
• Figure ground discrimination
• Binaural integration and separation
• Appropriate hemispheric lateralization
 Does he perceive tactile or proprioceptive information
correctly?
If we don’t receive information correctly, we
cannot learn correctly!
Visual Form Constancy
Match the picture on top with one of the four choices.
1.
2.
3.
4.
Visual Form Constancy
What is added to the first picture to make the second picture?
1.
First Picture
Second Picture
to
2.
First Picture
Second Picture
to
3.
Second Picture
First Picture
to
Visual Figure-Ground
Discrimination
1.
How many times is the number 8 in the above picture?
7 times
10 times
8 times
5 times
2.
How many times is the number 6 in the above picture?
10 times
4 times
5 times
1 time
3.
How many times is the number 9 in the above picture?
9 times
3 times
15 times
2 times
Treating sensory issues
Developmental Optometry
 Tracking
 Figure ground discrimination
 Bilateral use exercises
Audiology
 Pairing with visual input
 Noise reduction headphones
 Practice the hemispheric deficit areas
Tactile/Proprioceptive
 Sensory Integration/OT
 Sensory Diet to regulate
Sensory Regulation Activities
 Teaching self soothing activities
 Using environmental stimuli to prevent sensory overload
Experiencing the world through Autism
Little or no sleep
Stomach pain, bloating, discomfort
Diarrhea and/or constipation
Lights are too strong or piercing
Sounds are too intense
Background noise is loud
Objects are not in focus
Everything is unpredictable
Do individuals with autism
experience anxiety?
Signs of Anxiety in Autism
 Self stimulatory behavior
•
•
•
•
Ordering, lining up
Hoarding
Checking
Avoiding
 Social Activities
 Eye Contact
 Demands
 Self injury?
Treat the Anxiety
Reduce demands until skills are mastered
Reward frequently
Teach coping strategies
Allow functional levels of compulsivity
Improve Sleep
Improve Chemistry
 SSRI
 SNRI
Teach New Learning Patterns
ABA: Applied Behavior Analysis
 “30 years of research demonstrated the
efficacy of Applied Behavioral methods in
reducing inappropriate behavior and in
increasing communication, learning and
appropriate social behavior”
Surgeon General, 1999
Outcome Research on ABA for Autism
Lovaas (1987)
Sallows (2005)
Howard (2005)
Cohen (2006)
Eikeseth (2007)
Remington (2007)
Perry (2008)
1987: Behavioral Treatment and Normal
Educational and Intellectual Functioning in
Young Autistic Children
Experimental
47%
40 hours/wk
Recovered!
Group:
N=19
3 yrs
10 hours/wk 10 hours/wk
UCLA/NPI
3 2%
yrs Recovered
Control
3 Control
yrs
Group 1:
N=20
Group 2:
N=20
40 hrs/week ABA for 2 or more years
47% achieved average IQ and required
no special education after treatment
McEachin (1993): gains maintained for
8/9 when the children were 12 years old
4 years of ABA
Results:





Average IQ: 48%
Success in unsupported regular education:
34%
Non-impaired communication: 42%
Non-impaired socialization: 42%
Failure to qualify for autism according to the
ADI-R: 34%
3 years of ABA
Results:



Average IQ: 57%
Success in unsupported regular
education : 28%
Non-impaired on the Vineland adaptive
behavior composite: 38%
Replication in Norway
2 years of ABA
Results:
 Average IQ: 7/13 = 54%
 Average score on Aechenbach
CBC: 4/13 = 31%
Replication in England
25 hrs/week of ABA for 2 years
 Gains in language, intelligence, daily
living, positive social behavior
 No increase in parent stress
Replication in the Middle East
Results:
 Scoring in non-ASD range on
ADOS after treatment: 4/19 = 21%
Whole province of Ontario, Canada
Free ABA for all young children with autism
332 children
71% made significant gains
11% achieved functioning in the average
range
Poor quality control, lots of different
providers, still had large good effects
Outcome Research on ABA for Autism
Conclusions of outcome research




Every published study demonstrated very
large treatment effects
Replicated across research groups, across
university vs. community settings, and across
continents
Intensity matters: at least 25 hours per week
of one-to-one intervention for more than a
year produces best outcomes
Duration matters: two or more years of
intervention
Outcome-Level Analysis of ABA
Treatment for Autism
Effects of age and
treatment intensity
on outcome
N = 245
More treatment =
more gains
Published in
Research in Autism
Spectrum Disorders
(2009)
Recovery from Autism
Retrospective analysis of charts in 38 cases of
recovery following ABA treatment
In-press in Annals of Clinical Psychiatry
Acceptability of ABA
The following bodies now recommend ABA as a
treatment for autism




American Academy of Pediatrics
The New York State Department of Health
The National Academy of Sciences
Surgeon General
• “30 years of research demonstrated the efficacy of Applied
Behavioral methods in reducing inappropriate behavior and in
increasing communication, learning and appropriate social
behavior”
Surgeon General, 1999
Integrative Treatment
Medical
Interventions
Eliminate Triggers
Stabilize
underlying
cause
Achieve health
Sensory
Interventions
Develop and
Regulate
sensory input
ability
Behavioral
Interventions
Teach new
learning
patters
Generalize to
daily living
Why would a behaviorist care
about biomedical interventions?
1990: Andrew was diagnosed with
Celiac…we placed him on a diet and he
recovered within a year!
1992: I began to notice a pattern of children
with extremely high use of antibiotics! This
must be leading to some abnormal flora!
1993: Emily had fungus on her
nails…treated with antifungals, her
behavior changed drastically!
Preliminary Outcome Study:1996
79 children
63 boys
16 girls
Average age at intake: 39.1 months
Average IQ at intake: 76.8 (borderline)
Length of time in treatment: 3 years
Preliminary Outcome Study:1996
High Intensity
Low Intensity
More than 25 hours/week
Less than 25 hours/week
44 children
35 children
Matched on age, IQ,
language, adaptive behavior
Results: Outcome 1996
Mean Client IQ Pre- and Post-Treatment
IQ Standard Score
100
High Intensity
95
90
85
80
75
70
Low Intensity
1
Pre-Treatment
2
Post Treatment
Mean Adaptive Functioning Pre- and
Post-Treatment
Vineland Standard Score
100
95
High Intensity
90
85
80
75
70
Low Intensity
65
60
1
Pre-Treatment
2
Post Treatment
Normal Cognitive Functioning
WPPSI: Pre- & Post-ABA Early Intervention
Pre-Test
130
120
Post-Test
110
Intelligence Quotient
100
90
80
70
60
50
40
30
20
10
0
20
22
27
29
29
30
30
31
Average Therapy Hours Per Week
31
31
32
34
38
Why didn’t we publish this?
1996 Outcome Study Confounding Variable:
• A higher percentage of children in the
high intensity group were receiving
biomedical interventions!
• Was the improvement in IQ and
adaptive skills due to ABA or due to
the medical interventions or a
combination???
Let’s look at some case studies of children
who improved significantly with a
combination of medical and behavioral
treatment
D.R.
Diagnosis: Autism
Intake:
 Age: 2.11
 Deficits: receptive vocabulary of 10 words, 3 expressive words used for
needs (juice, open, ball), no eye contact, severe tantrums, crying,
aggression and elopement, ssb included gazing, mouthing objects and toe
walking.
Treatment:
 1 year 10 months with CARD to date
 Average intensity of 30 hours/week
 Specific Carbohydrate Diet
Current:
 Age: 4.9
 In typical preschool with aide
 175 mastered receptive labels, mands and tacts with all items using full
sentences, maintains eye contact up to 8 seconds, responds to name by
making eye contact and saying “yes” or ‘what”, answers 23 social
identification questions, interacts with adults average of 10 minutes/peers
2 minutes. Ssb reduced but still exist, aggression and noncompliance have
extinguished.
D.R.: New Skills per month
New Skills per Month
250
ABA + IgG
Allergy
Elimination
Diet +
Feingold Diet
+
Rotation diet
ABA + Specific Carbohydrate Diet
200
150
100
50
0
Nov-03
Dec-03
Jan-04
Feb-04
Months
Mar-04
Apr-04
May-04
Jun-04
DR
Frequency of Stereotypy per Month
D.R.: Stereotypy per month
800
700
600
ABA + IgG
Allergy
Elimination
Diet +
Feingold
Diet +
Rotation
diet
ABA + Specific Carbohydrate Diet
500
400
300
200
100
0
Nov
Dec
Jan
Feb
Mar
April
May
June
Months
DR
Visual SSB
Verbal SSB
Oral Motor SSB
Tactile SSB
Frequency of Aggression per
Month
D.R.: Aggression per month
100
90
80
70
ABA + IgG
Allergy
Elimination
Diet +
Feingold Diet
+
Rotation diet
ABA + Specific Carbohydrate Diet
60
50
40
30
20
10
0
Nov
Dec
Jan
Feb
Mar
Months
April
May
June
DR
Emma
Diagnosis: Asperger’s Syndrome
Intake:
 Age: 3.4
 Deficits: poor eye contact, extensive vocabulary but did not use
language with peers, self-isolated at school, severe tantrums, non
compliance and aggression with family, visual self-stimulatory
behaviors, severe ritualistic behavior, no Theory of Mind
Treatment:




10 months with CARD
Average intensity of 10 hours/week
Lexapro
Pro DHA and CorOmega
Exit:
 Age: 4.2
 In typical kindergarten with no aide
 Initiated conversations with peers, many friends, no tantrums or
aggression, very advanced in academic skills and very popular in
school
Emma: Challenging Behaviors per month
ABA
ABA +
Lexapro
ABA +
ProDHA +
Coromega
Frequency per Session
7
6
5
4
3
2
1
0
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Months
Tantrums
Non-Compliance
Ritual SSB
Emma
Emma: New Skills per month
ABA +
Lexapro
ABA
ABA + ProDHA
+ Coromega
New Skills per Month
120
100
80
60
40
20
0
Mar 04
April 04 May 04 June 04
July 04
Months
Aug 04
Sept 04
Oct 04
Nov 04
Dec 04
Emma
A. D.
Diagnosis: Autism
Intake:
 Age: 2.11
 Deficits: had 3-4 word utterances but no spontaneous language, selfisolated around peers, no safety awareness, toe walking, licking hands,
had difficulty inhibiting responses and would often touch people’s hair or
clothing.
Treatment:




3 year with CARD
Average intensity of 25 hours/week
Anti-fungals
Chelation
Exit:
 Age: 5.11
 In typical kindergarten without aide
 Initiates, joins, transitions conversations with peers, has many friends,
good understanding of others perspectives, no challenging or selfstimulatory behaviors present. Normal range on all exit testing (IQ,
language, TOM, EF)
A.D.: Challenging Behaviors per month
ABA +
Antifungal +
Chelation
ABA
12
10
8
6
4
2
Fidgeting
Grabbing
June
May
AD
Month
Elopement
Running
April
March
Feb
Jan
Dec
Nov
Oct
Sept
Aug
July
June
0
May
Frequency per Hour
14
Leaning
Screaming
A.D.: New Skills per month
ABA +
Antifungal +
Chelation
ABA
200
150
100
50
Month
June
May
April
March
Feb
Jan
Dec
Nov
Oct
Sept
Aug
July
0
June
New Skills per Month
250
AD
What do we learn from these
Case Studies?
A variety of medical interventions worked
for these children
Each child benefited from a different type
of intervention
Autism is a “Spectrum Disorder”…children
with Autism are very different from each
other!
Not every intervention will work for every
child….except for ABA!
What is Applied Behavior Analysis
ABA is based on the principles of
Operant Conditioning Theory:
“Human Behavior is affected by events
that precede it (antecedents) and events that
follow it (consequences)”
Change these events…change Behavior!
What does that mean?
In ABA we change behavior by changing
antecedents and consequences
What is a behavior?
 Behavior is anything we do
What is an antecedent?
 An Antecedent is whatever happened just
before the behavior
What is a consequence?
 A Consequence is whatever happens just after
the behavior
What behavior do we want to change?
Deficits





Language
Play
Social Skills
Theory of Mind
Executive Functions
Excesses
 Self Stimulatory Behs
 Maladaptive Behs
• Tantrums
• Aggression
• Noncompliance
Skill Repertoire Instruction Behavior Management
Give rewards for these Remove rewards for these
Why does a child have challenging
behaviors?
Everything we do is to
 Get a Reward
 Avoid a Punishment
Challenging Behavior is the child’s way of
telling us what he wants
He may not realize that his way of telling
us is not the “appropriate way”
He may not have the skills to tell us the
appropriate way!
What is this child trying to get?
Positive things children want:
Attention
good or bad
Tangibles
our favorite foods
fun activities
toys
playground
Negative things children avoid
 Having to work
 Classroom
 Listening to people telling us what to do
 Giving up something we want to keep
doing
 Sensory Overload
 Getting ready in the morning
How do we change Behavior
Give
positive
Remove
+ ReinforcementResponse Cost
Extinction
Behavior
Behavior
negative Punishment
Behavior
- Reinforcement
Behavior
How do we change behavior?
Change behavior by changing the
antecedent or the consequence or both!
Teach Todd to
ask when
Todd
wantshe
toy
wants toy
Todd
will
not
hit
Todd hits
will not
hit
Todd
sibling
sibling
sibling
Todd
not
Todd does
gets toy
get toy
Jon
Jon learns
hates
skills
so he
school
likes school
Jonscreams
will not
Jon
scream
Jon
Jonisissent
not
sent
home
home
Mark
does
Mark
cries
and
something
tantrums
appropriate
Mark
gets
Markdoesn’t
gets
Mark
attention
attention
get
attention
Teach
Mark to
Mark wants
doattention
something
appropriate
Step 1: Identifying what the child wants to
communicate
Step 2: Teaching the child more
appropriate ways to communicate
If we teach appropriate communication
skills, they will replace challenging
behaviors in our kids
Challenging behaviors are NOT part of
the Autism diagnosis! They are just a
form of communication!
Summary
Identify the behavior you want to change
Identify why it is happening
 What is your child trying to communicate?
 What does he want to have or avoid?
Now that you know the function, you can change
the behavior
How?
By changing either the antecedent or the
consequence…or both!
The FUNCTION of the behavior tells you what to
do!
Extinction for Tangible Function
Example of DRA
The Secret to successful ABA
The key is to teach appropriate skills!
If a child has appropriate skills, and they are
easy to do, he will not engage in
challenging behaviors!
We cannot simply “extinguish” challenging
behaviors without replacing them first, with
appropriate skills!
We learned how to use ABA to change
behavior
Now lets look at how we can use ABA to
teach skills
Same principles
What behavior do we want to change?
Deficits





Language
Play
Social Skills
Theory of Mind
Executive Functions
Excesses
 Self Stimulatory Behs
 Maladaptive Behs
• Tantrums
• Aggression
• Noncompliance
Skill Repertoire Instruction Behavior Management
Give rewards for these Remove rewards for these
The CARD Curriculum
Executive
Functions
Play
Cognitive
Language Adaptive
Motor
Social
Academic
The CARD Curriculum
Language
By Emerging Age and Verbal Operant:
0-11 mos.
Choices
Listen to/Tell a
StatementBody Parts
Fast Mapping Story
Statement
Locations
Following
Functions
4:0-4:11 yrs.
Instructions
Negation
Objects
Describe by
Gestures
Plurals
Opposites
Category/Feature/
Making
Recalling Events
Prepositions
Function
Requests
Sound Speed &
Pronouns
Phonic Same/
People
Duration
2:0-2:11 yrs.
Different
Sound
Syllable
Adverbs
StatementDiscrimination
Segmentation
AttributeQuestion
Verbal
WhObject
What Goes With
Imitation
Discrimination
Conditionality3:0-3:11 yrs.
5:0-5:11 yrs.
Yes/No
Deliver a
Observational
1:0 – 1:11 yrs.
Minimal Pairs
Message
Learning
Actions
Same/Different
Features
Syntax
Asking for
Sequences
Gender
Information
Sound Changes
I
Have/ISee
Categories
Mixed Operants
Play Curriculum
Play
Domains
Sensorimotor Play
Task
Completion
Play
Beginning
Play
Initiating and Sustaining Play
Block Imitation
Structure
Building
Constructive
Sand and Water Constructions
Play
Clay Constructions
Arts and Crafts
Audio and Video Play
Computer
Play
Electronic
Play
Video Games
Early Social Games
Read-to-Me
Books & Nursery Rhym
Interactive
Music and Movement
Play
Treasure Hunt
Card and Board Games
Locomotor Play
Peer Play
Pretend
Functional
Pretend Play
Play
Symbolic Play
Imaginary Play
Sociodramatic Play
Interactive Play: Nursery Rhymes
Adaptive Curriculum
Adaptive
Personal
Feeding
Toileting
Undressing
Unfastening
Dressing
Preventing Spread of Germs
Bathing
Fastening
Teeth Care
Hair Care
Nail Care
Health Care
Community
Shopping
Restaurant Readiness
Domestic
Pet Care
Setting & Clearing Table
Telephone Skills
Tidying
Meal Preparation
Cleaning
Gardening
Laundry
School Backpack Prep
Making a Bed
Safety
Safety Awareness
Safety Equipment
Motor Curriculum
Motor
Oral
Visual
Fine
Gross
The CARD Curriculum
School
Skills
Math
Number ConceptsLanguage Arts 1
Rote Counting
Language Arts 2
Reading
Reading Numerals
Visual Discrimination
of Symbols Writing
Manuscript
Numeral Comprehension
Reciting Alphabet
Science
Printing Symbols
Ordinal
Position
Physical Education
Numerals in SequenceUppercase LettersPersonal Data
Lowercase Letters
Lowercase Letters
Addition
Word Recognition
History
Uppercase Letters
Subtraction
Orally
Letters
in Sequence
Advanced Counting ReadingSocial
Studies
Reading Comprehension
Letters Dictated
Money
Book Topography
Simple Sentences
Time
NonAcademic
Story Comprehension
Quality of Printing
Story Summarizing Skills
Text Comprehension
The CARD Curriculum
Cognition
Cognition:
 Meta-cognition: Identifying your own …
 Social Cognition: Inferring others’…
Emotions
Thoughts
Knowledge
Desires
Beliefs
Intentions
Classic Test of Social Cognition
“Sally-Anne” or False-Belief Task
Where will Sally look for her ball?
Where does she think her ball is?
Cognition
“Typical” Meta and Social
Cognitive Development
Cognition
First few months: Sense of Self
9 months: Joint Attention / Social Referencing
15 months: Pretence
18 months: Desire / Intention
2 years: Emotion
3 years: Knowing / Thinking
4 years: Belief / False-Belief
5 years: Intention – Accident vs. Purpose
Cognition Curriculum
Cognition
13 Lessons
Preferences
Desires
Sensory
Perspective
Taking
Physical States
Emotions
Cause &
Effect
Senses
Understanding other perspectives
Social Skills Curriculum
Non-Vocal
Social
Behavior
Social
Skills
Social Language
Social
Absurdities
Greetings and Salutations
Non-Vocal Social Behavior
Language
Social ID
Questions
Eye Contact
Prosody
Non-Vocal Imitation
Regulating Others
Body Language & Facial Expressions
Absurdities
Conversational Audience
to Regulate Social Interaction
FiguresGestures
of Speech
Social
Interaction
Physical Context
of Conversation
Humor and Jokes
Apologizing
Listening to Conversation
What’s Wrong?
Assertiveness
Initiating Conversation
Compliments
Joining Conversation
Cooperation
& Negotiation
Maintaining
Conversation
GroupGroup Related Skills
Attention
Social
RepairingGaining
Conversation
Related
Responding in Unison
Introductions
Interaction
Transitioning Topics
of Conversation
Skills Group Discussion
Levels
of
Friendship
Ending Conversation
Sharing & Turn Taking
Social Rules
SelfLending
Esteem & Borrowing
Compliance
Dealing with Conflict
Following Rules
Positive Self-Statements
Community Rules
Social Context Winning & Losing
Politeness & Manners
Constructive
Criticism
Responding to Social
Cues
Learning Through Observation
Social
Skills
Social
Self Esteem
Responding to Social Cues
The CARD Curriculum
What is Executive Function?
 Process that underlies goal
directed behavior
Goal Directed Behavior Involves…
Visualizing situation
Identifying desired objective
Determining plan to meet
objective
Monitoring progress to goal
Inhibiting distractions
Executive
Functions
Executive Functions
Curriculum
Inhibition
Planning
Waiting,
Physical / Motor,
Vocal,
Inhibition
Pencil / Paper
Task / Social
Goal Setting, Previewing,
Task Initiation,
Monitoring Progress,
Time Management,
Planning
Organizing Materials,
Using a Planner,
Self-Organization
Meta-Cognition
MetaMeta-cognitive Planning,
Cognitive
Self-Evaluation, Meta-memory,
Planning
Self-Monitoring
of Attention,
Emotions, Reinforcement Control,
Study Skills, & Flexibility
EF
Flexibility/
Set-Shifting
Executive
Functions
Non-Social,
Social,
Flexibility
Social –Cognitive, Attention
Situational
Social Orienting,
Joint Attention,
Sustained, Divided, &
Alternating Attention,
Determining Saliency,
Attention
Depth of Processing,
Paraphrasing,
Task Persistence
Problem
Problem
Solving
Solving
Non-Social,
Social
Memory
Associative,
Memory
Visual, Spatial,
Auditory, Episodic,
Working
Children’s Color Trail Test
Stroop Activities
Problem Solving: clarification
Telling Jokes
Summary
A good ABA program requires good
assessment to determine exactly what your
child needs to learn!
A good ABA program needs a lot of hours!
Don’t do 5 hours of ABA when 40 hours
are recommended! This is like taking 5 mgs
of a drug that has shown to be effective at
40 mgs! It wont work!
A 4 year progression
Year 1:
 Child entering at age 2-3
 25 hours per week building to 40 hours
 Emphasis on
• Building a relationship with child
• Replacing challenging behaviors with
functional communication
 Mands (Requests)
 Tacts (labels)
• Receptive identification (objects,
actions, body parts, colors, shapes)
• Receptive instructions
• Verbal and Non-verbal Imitation
• Identical Matching
• Play Skills (toy play)
• Adaptive Skills (toilet training)
• Fine and Gross Motor
• Dietary restrictions/medical compliance
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
A 4 year progression
Year 2:
 Child age 3-4
 40 hours (in home with partial transition to school)
 Emphasis on
• Building Expressive Language
 Objects, Actions, Attributes, Prepositions, Pronouns
 Categories, Functions, Occupations, Locations
• Beginning Conversation
 Intraverbals
 Reciprocal Statements
 Asking Questions
• Developing Observational Learning
 I See
 Sequences
 Tell me about/Describe
•
•
•
•
•
•
•
Emotion Recognition
Inferring others desires
Play Skills (functional pretend, symbolic, imaginary)
Adaptive Skills (dressing, grooming, feeding)
Fine and Gross Motor
Sharing and Turn taking
Attention (dual and divided)
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
A 4 year progression
Year 3:
 Child age 4-5
 40 hours (20 hours at home; 20 hours at school)
 Sample Programs
• Advanced Language Concepts
 Pragmatic Language
 Maintaining Conversation (topic initiation, repair,
maintenance)
• Meta and Social Cognition
 Identifying and Managing own emotions
 Understanding other’s Perspectives, Knowledge
and Beliefs
 Inferences
• Executive Function




Attention Saliency
Flexibility with Routines
Inhibition and Self Monitoring
Planning
• Social Skills
 Levels of Friendship
 Recognizing Social Cues
•
•
•
•
Problem Solving
Play Skills (peer play dates)
Adaptive Skills
Fine and Gross Motor
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
A 4 year progression
Year 4:
 Child age 5-6
 40 hours (10 hours at home; 30
hours in school and fading
services)
 Emphasis on
• Teacher and Parent training
• School Skills
 Listening and Reading
comprehension
 Math and Problem Solving
• Advanced Social Skills
 Detecting Sarcasm
 Understanding Deception
 Group Skills
• Continued Self Regulation
 Self Esteem and Confidence
 Task and Social Planning
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
Summary
Treat each child differently
Identify the medical issues that need
treatment and treat them so that the child is
medically stable, sleeping well and
attending
Identify the sensory deficits that may be
prohibiting normal learning so that you can
modify the way you teach
Use ABA techniques to teach the child all
the things he is lacking

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