Agenda Understanding ASD · 2/29/16 1 Video Modeling and Social Skills Training for Students with...
Transcript of Agenda Understanding ASD · 2/29/16 1 Video Modeling and Social Skills Training for Students with...
2/29/16
1
VideoModelingandSocialSkillsTrainingforStudentswithASDinthe
SchoolsandBeyond7th AnnualNSSHLAConferenceatChicoState
March5,2016LynneHewitt
BowlingGreenStateUniversityBowlingGreen,[email protected]
Disclosure
• Dr.Hewitt teaches, presentsandpublishesonautism spectrum disorders; she isa facultymember andadministrator atBowling GreenState University andhassupervised graduateclinicians in theSpeech &Hearing Clinic forclientswith ASD.Shehas received compensationfromNSSHLA ChicoState aswell asreimbursement for travel expenses forgiving thispresentation. Shehasnoother financial ornon-financial disclosures tomake.
HewittMarch2016 3
Agenda• 9-10A.M.• Roots ofsocialpragmaticimpairments inASD
– Neuro logical unde rp inn ings– Cogn itive conse que nce s– Co -morb id d iso rde rs
• 10-11A.M.• Typesofproblemsandconsiderations forassessment/baselining
– Schoo lage ch ild re n• Case e xamp le
– Ado le sce n ts• Case e xamp le
– Adu lts• Case e xamp le
• 11-12A.M.• Interventions andsupports forsocialcommunication
– Schoo lage ch ild re n• Case e xamp le
– Ado le sce n ts• Case e xamp le
– Adu lts• Case e xamp le
• 1-2P.M.• Visualapproachestolearningandself-regulation
– Why visual. Comp le x in fo rmation p roce ssing in ASD.– Static app roache s, visual sche du le s,e tc.– Dynamic--vide o -base d
• Vide o mode ling• Vide o se lf-mode ling
• 2-3P.M.• Evidencebaseforvideomodeling
– Source s o f re ady-made mate rials
• 3-4P.M.• Creatingyourownvideomodels .• Q&A HewittMarch2016 4
UnderstandingASD
• Aspectrum• Likelihood ofmultiple causes• Co-morbid conditions• “autisms” not“autism” ?
HewittMarch2016 5
DiagnosingAutismintheU.S.,DSM-V:(June 2013)
– Diagnostic & Statistical Manual of Mental Disorders, fifth edition. American Psychiatric Society.
– Major changes from older editions• Helps bring clinical dx in line with current research• Helps bring consistency to diagnostic practice• Somewhat more in line with the International
Classification of Diseases used by most countries (ICD-10)
– Useful summary available here:• https://www.autismspeaks.org/what-
autism/diagnosis/dsm-5-diagnostic-criteria
HewittMarch2016 6
Twocoreimpairments neededfordiagnosis ofASD
– 1. Persistent deficits in social communication and interaction• Deficits in social-emotional reciprocity• Deficits in non-verbal communicative behavior for
social interaction– Gestures, facial expression, gaze
• Deficits in developing, maintaining, understanding relationships
HewittMarch2016 7
2/29/16
2
DSM-Vcoreimpairments, cont
• 2. Restricted, repetitive patterns of behavior– Stereotyped or repetitive motor movements, use of
objects, or speech– Insistence on sameness, inflexible adherence to
routines or ritualized patterns of verbal or non-verbal behavior
– Highly restricted fixated interests, abnormal in intensity or focus
– Hyper- or hypo-reactivty to sensory input, or unusual sensory interest
HewittMarch2016 8
Otherconsiderations
• Mustresult infunctional limitations• Mustoccur during earlydevelopmental period• Should notbebetter explained byintellectualdisability– Ifintellectualdisabilitysuspected,mustconfirmthatsocialcommunicationabilitybelowexpectationsforleveloffunctioning
HewittMarch2016 9
LevelsofseverityusedinDSM-5
• Level3Requiring verysubstantial support• Level2Requiring substantial support• Level1Requiring support
SeeDSM-VASDsummary at:https://www.autismspeaks.org/what-
autism/diagnosis/dsm-5-diagnostic-criteria
HewittMarch2016 10
Considerations indiagnosis
• Individuals without restrictive/repetitivebehaviors mayfallunder socialpragmaticcommunication disorder– NOTE: thisdxfallswithinourscopeofpractice– Notwidelyused/wellunderstoodasyet
HewittMarch2016 11
ThoughtExperiment• Imagineyouare invited toaparty.
– Youdon’tknowanyone– Youarenotsurewhatisgoingtohappenorwhatisexpectedofguests– Youareunsurewhenitbeginsandends
• Yougetup yourcourageandgoanyway– Thesocialexpectationsarecompletelyconfusing
• Youcan’tf igureouthowtotalktopeople—whoisopenandwhoisbusy– It’sreallyloudso it’shardtohearandunderstandanythingthatis said– Thereisadiscolight setupso it’shardtoseepeople’sfaces– Thetemperatureisuncomfortable,andit’scrowded– Thereisnothingyouliketoeatordrink– Therearenoactivitiesyouliketodo– Somepeoplegetupsetwithyoufornotdoingwhat’sexpected– Soyougetupset--noonetoldyouwhatwasexpectedandnooneishelping
youfindout• Theythinkyoushouldjustknow,butthatisimpossible.
HewittMarch2016 12
Howweareusedtothinkingofthebrain
HewittMarch2016 13http:/ /www.biausa.org/ living-wit h-b rain -injury.htm
2/29/16
3
Issues in studying the brain
• Naïve localizationism
HewittMarch2016 14
Howweneedtostartthinkingaboutthebrain
HewittMarch2016 15
http://www.semel.u cla. ed u/ bdd an or exi a/r ese ar ch/ pr oje ct/visual-functional- co nn ectivi ty
http://commons .wiki me dia .o rg/wi ki/ File: Net wor k_ re pr esentation_of_b rai n_c on ne ctivity. JPG
Neurobiology of ASDvASD is now well understood to be disorder
of neurobiologyvIncreased risk of seizuresvCo-morbidity with other disorders
vADD, ADHDvAnxietyvDepressionvObsessive-compulsive disordervOther psychiatric disorders
vE.g., Tourette syndrome
HewittMarch2016 16
Advancesinneuroscience forASD
• Widespread brain differences– The landscapeofthebrainisdifferenteverywhereonelooks
HewittMarch2016 17
What do we know about the brains of persons with autism?
§ Obvious lesions not present§ Adult brain size usually within average
range§ Poss. macrocephaly in childhood
§ Subtle abnormalities widespread throughout brain§ Amygdala§ Cerebellum§ Frontal lobe
HewittMarch2016 18
Research on brain structures & connectivity in ASD
• https://www.youtube.com/watch?v=BdMmPXgTGhc– Slide minute 3:54 on structures that are anomalous in the brains of
individuals with ASD. R. Muller
HewittMarch2016 19
2/29/16
4
Issues in studying the brain
§ Pitfallsinapplyingknowledge fromacquired todevelopmentaldisorders§ Developmentmatters!§ Sometimeslesionsshedlight§ PhineasGage
HewittMarch2016 20
Recent breakthroughs
• Problem is not one system but connection between systems– Brain as an emergent system
• Dendritic growth and pruning• Adult brain structure arises from gene-
environmental input interaction– Structural differences in brains raised in deprived
environments
• Plasticity
HewittMarch2016 21
One example of long-distance connectivity problems
vCourchesne and colleagues vMany papers showing cerebellar anomalies
vWhat does cerebellum do?vMotor planning, learning, execution
vHow could that relate to features of autism?vLogically, seems that frontal lobe must be involved
vFindingsvAbnormal connections between frontal lobe and
cerebellumvAbnormal rate of brain growth in early life
vPrimarily attributable to frontal lobevAbnormal structure of frontal lobe neurons
HewittMarch2016 22 HewittMarch2016 23
Quote from Courchesne & Pierce (2005)
Maldevelopment onthisscale,therefore,verylikelyreflectssubstantialdefectsrangingfromneuronalnumberstomolecularfunctionandlocalandlong-distanceconnectivity.Therecognitionofthisprocessasongoingandmassiveremindsthatautismisindeedadisorderofthedeveloping brain.Inthedevelopingbrain,theneuralstructuralandfunctionallandscapeiscreatedwherenoneexistedbefore,andsowhenaspectsofthisprocessgosubstantiallyawry,weshouldexpecttoseeadifferentlydetailedlandscape(connectivity,molecularexpression,etc.)andnotsimplyalargelynormallandscapewithperhapsjustoneortwospecificfeaturespreciselyandconvenientlyomittedorchanged.
HewittMarch2016 24
Minshew & Williams (2007)
• Review of research in neurobiology• Key issues
– Polygenetic disorder
HewittMarch2016 25
2/29/16
5
Minshew & Williams, cont.
• Systems affected in autism – Not focal (localized)– “Distributed neural systems abnormality”
• Head growth abnormalities– Increase in white and grey matter
• Not just neural connectivity issue– Minicolumn abnormalities
HewittMarch2016 26
Minshew & Williams
• Problems with inhibition, excitation– Reduced boundaries between minicolumns
• Gray and white matter both involved in ASD– Gray matter: neuronal cell bodies– White matter: myelinated axons (and glial
cells)
HewittMarch2016 27
Minshew & Williams, cont.
• Decreased interhemispheric connectivity– Reduced size of corpus callosum
• Abnormal intrahemispheric connectivity
HewittMarch2016 28
Minshew & Williams, cont.
• FMRI findings– Atypical timing, patterns of activation
• Language tasks• Working memory• Problem solving• Social Cognition
HewittMarch2016 29
Minshew & Williams, cont.
• Sensory differences– New brain findings indicate sensory
processing differences core to ASD• “…autism had a far broader impact on the brain
than was originally conceptualized.” (p. 949)
HewittMarch2016 30
Recent work in neuroimaging
• Eigsti et al. (2016) investigated language processing using FMRI, in 3 groups: – Optimal Outcome children and adults with ASD (OO)
– High functioning autism (HFA)
– Typical peers (TD)
• Findings:– OO and HFA showed similar patterns of processing– OO also showed more effortful processing than HFA
HewittMarch2016 31
2/29/16
6
Eigsti et al., cont.
• Implications:– IndividualswithASDusedifferentstrategiestoprocesslanguage• Even–andespecially!--whenapparentlyindistinguishablefromNTpeers
•Reference:Eigsti, I-M,Stevens, M.,Schultz, R.,Barton, M.,Kelley, E.,Naigles, L.,Orinstein, A.,Troyb, E.,and Fein, D.(2016).Languagecomprehension andbrain function in individuals with anoptimal outcome fromautism.Neuroimage: Clinical, 10,182-191.
HewittMarch2016 32
Caution on neuroscience
“Itshouldbekeptinmindthatdespitetherapidtechnicaladvancesinthefield,MRItechniquesremainlimitedtoalevelofspatialandtemporalresolutiontoocoarsetovisualizethesynapticorneuronal-levelabnormalitiesthatmaybecorefeaturesofdisorderssuchasASD.Ifthisisthelevelfromwhichheterogeneityarises,neuroimagingmayultimatelynotbethebesttoolforparsingthesedifferences.”
Lenroot,R.K.,&Yeung,P.K.(2013).Heterogeneitywithinautismspectrumdisorders:whathavewelearnedfromneuroimagingstudies?.FrontiersinHumanNeuroscience,7,733.
HewittMarch2016 33
“Thebrainsofhumansarethereforemeanttomakemeaningoutoftheirsurroundingenvironment.Unfortunately,incertainconditions,likeautism,thiscapacityforcontrastappearsdiminished.”
Availableat:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384515/
Casanova,M.F.(2010).Corticalorganization:adescriptionandinterpretationofanatomicalfindingsbasedonsystemstheory.TranslationalNeuroscience,1(1),62–71.http://doi.org/10.2478/v10134-010-0002-2
HewittMarch2016 34
Puttingitalltogether
• Social communication andsocial cognitionrequire– Rapid decision-making
• Incomplexenvironments– Facialprocessing abilities,recognizing emotions, etc.– Language– Abilitytofilteroutirrelevantinformation– Abilitytohold(atleast) twoseparateviewsatonce:
• Ownview• Communicativepartner’sview
HewittMarch2016 35
Cognitive issues
• Theoryofmind• Executive functioning• Impairment incentral coherence• Attention deficit disorder• Intellectual disabilities• Learning disabilities
HewittMarch2016 36
Otherco-morbidities
• Depression• Anxiety• Obsessive-compulsive disorder• Bipolar disorder
HewittMarch2016 37
2/29/16
7
Otherfactors
• Sleepproblems– https://www.disabilityscoop.com/2016/02/18/autism-behavior-poor-sleep/21930/
• Other co-morbid physicalproblems– Foodaversions,intolerances– http://www.sciencedirect.com/science/article/pii/S0882596313000961
– Increasedratesofseizuredisorders
HewittMarch2016 38
Sensory issues
• Partofcore symptomatology– Hyper-responsiveness– Hypo-responsiveness– Maybothbepresentinsameindividual– Relate toASDsymptomseverity,socialpragmaticdifficulties
• Glod,M.,Riby,D.M.,Honey,E.,&Rodgers,J. (2015).PsychologicalCorrelatesofSensoryProcessingPatternsin IndividualswithAutismSpectrumDisorder:ASystematicReview.ReviewJournalofAutismandDevelopmentalDisorders,2(2),199-221.
HewittMarch2016 39
Ourstudents• Whatistheworld likeforthem?• Whatwould anoptimal environment be?• Isatypical classroom agoodsetting forlearners with ASD?
HewittMarch2016 40
AdvantagestoInformalAssessment
• Clinician determines whattomeasure, basedonconcerns andexpertise
• Abletocollect dataabout natural behaviorsandreal-world functioning
• Canusedatacollected asbaselines forintervention goals
HewittMarch2016 41
DisadvantagestoInformalAssessment
• Ifartificial cut-off scoresrequired toaccessservices, cannot obtain frominformalmeasures
• Needmore expertise tointerpret– Knowledgeoftypicaldevelopment
• Normslackingforpragmatics,unclearwhatmetrics– E.g.,how toquantify “tactful communicator”?
• Maybemore time-consuming
HewittMarch2016 42
LimitationsofFormalTesting forLanguage &Communication inASD
• Manytests’ norming populations do notincludeindividualsw/ASD– E.g.,PPVT-4attemptedfullrangesamplingreflectingpopulationsnorms--ithasexactly4participantsbetweenagesof2and18withASDinitsnormingsample
• Areasof languageand communication withmostsignificantweaknessesmaylackformal tests– Gestural communication– Prelinguistic andminimallylinguisticcommunicativedevelopment
– Pragmatics– Language tosupportsuccessintheclassroom
• Santhanam, S. & Hewitt, L. ( inpress) . Evidence-based assessment andautism spectrumdisorders: Ascoping review. Evidence-Based CommunicationAssessment andIntervention.
HewittMarch2016 43
2/29/16
8
FormalTestsRelevanttoSocialCommunicativeAssessmentinASD
• Communication and Symbolic Behavior Scales Developmental Profile™ (CSBS DP™, Wetherby & Prizant)• Early development screener
• Macarthur-Bates CommunicativeDevelopmentInventories– Validated forASD;good fortoddlers throughpreschool– Parent-administered checklist
• Children’sCommunicationChecklist(CCC)• PPVT
– Advantages: simple format;noneedforverbalexpression;well-normed;canrevealunsuspected competence
– Disadvantages:limited informationgleaned;noguidance forintervention
• CASLsubtests– Idiomaticlanguage;Pragmaticjudgment;Inference;Meaning from
context
HewittMarch2016 44
Suggestions forformaltests,cont.
• SocialResponsiveness Scale,2nd Ed.• TestofProblem-Solving (TOPS)
– ElementaryTOPS3– AdolescentTOPS2
• Functional AssessmentofVerbal ReasoningandExecutive Strategies(FAVRES)
• TestofLanguageCompetence, Inferencingsubscale
HewittMarch2016 45
SocialCommunication:approachestoassessmentusinginformalprotocols
• Assessing higher functioning individuals, especially adolescents andadults, canprovechallenging
• Importanceof communicationsampling• Documentationofbarrierstosuccessinregularcurriculum
– Common core ands tates tandards– Alsohidden curriculum
• Doubleinterview– AvailableinWinner, M.(2007). Thinkingabout you,thinking about me:Teachingperspective
takingand socialthinkingtopersons with socialcognitivelearningchallenges . (2nded.). SanJose,CA: ThinkSocialPublishing.
• Peerconf lictresolutiontask.– Nippold,M.A. (2014). Language samplingwithAdolescents ,2nd Ed.SanDiego,CA: Plural
Publishing• “Bigpicture”narrativecoding
– Barnes , J.,&Baron-Cohen, S.(2012). Thebigpicture: Storytelling ability inadults with autismspectrum conditions . Journal ofAutism &Developmental Disorders , 42(8), 1557-1565.doi:10.1007/s10803-011-1388-5.
• Narrativesof personalexperience– Rollins ,P. R.(2014). Narrative skills inyoungadults withhigh-functioning autismspectrum
disorders . Communication Disorders Quarterly, 36(1),21-28. doi:10.1177/1525740114520962
– Suggestionsforcollege-goingstudents/transitionplanning• Hewitt,L.(2015).Assessmentcons iderations forcollegestudents withautismspectrumdisorders .Topics in
LanguageDisorders ,34:4,313-328.
HewittMarch2016 46
Bestpracticesinassessment
• Takeamulti-pronged approach• Consider useofcaregiverreport instruments• Structured observations incritical contexts• Interview person, ifoldenough
HewittMarch2016 47
EBP:Clinicaldecision-making
• Singlemostimportant aspect ofeffectivepractice
• Pathwaystodecision-making:– Whatyoulearnedinschool– Yourpreviousexperience/beliefs– Whatyourcolleaguesdo/suggest– Whatisrequired/feasibleinyourworksetting– Whatfamilieswant– Scientificevidence
HewittMarch2016 48
EBPforbusyclinicians: Suggested“quick &dirty”strategies
– National StandardsProjecthttp://www.nationalautismcenter.org/about/national.php
– Google Scholar• Oftencannotgetfulltextarticles
– ASHA website• AllASHA journalsfreefull-texton- line
– Set upyour account and password• ASHAPracticePortalhttp://www.asha.org/practice-portal/
• Also try– Special interestwebsites:many free resources
• ASA• Apraxia-kids.org
• Togetaholdofinformation,maybearticles– Contactexpertinacademia
• Helps if theyare inyourlocalarea– Trye-mailing authorof articleyouareinterested in
• JoinSpecialInterestGroupofASHA– ASHA Community
http:/ /community.asha.org/ Discuss ions/Dig estVi ewe r/?Grou pId =265&Use rKey =e4f 77c70 -733c-422e-8d56-760f5 133 bfea&sK ey=05 B2E DEEF 2D04E 9A B027
HewittMarch2016 49
2/29/16
9
FundamentalsinInterventionforASD
• Grounded inbestcontemporary science• Appropriate toASDprofile
– Asneuroscience improves, interventionsmoreintentionallydesigned—more togoon todecidewhattodo
• Maybehavemoreimpact
• Early intervention nowshowntobenefitadaptivefunctioning, includingsocial functioning
• Gainspossibleatanyage– Though dearth ofresearch inolder adults
HewittMarch2016 50
BestPracticesinInterventionforSocialCommunicationImpairmentsinASD
• Level3individuals– Early interventionhasclearbenefitsinavertingsocialdeficits• EIBI• Jointattentionintervention• EarlyStartDenverModel
HewittMarch2016 51
HewittMarch2016 52
Take-awaymessagefrominfanteyegazestudy
• Fundamental cause ofASDmaybe“payingattention tothewrong stuff ”– Thatis,neglect ofsocial input and emphasis on objectinput skewsbraindevelopment
– Failtodevelopfundamental structures needed toprocess complex social info
• Emergent networksresponsibleforsocialknowledge
• Isthere apotential window fordivertingdevelopment backontothe right course?
• Is18months toolate?
HewittMarch2016 53
Whatinterventionsmighttargeteyegaze?
• In infancy?Unknown asyet• Toddlers/preschoolers?
– Naturalistic/social communication/focusedstimulation types
– Behavioralinterventions– Technology/Videos?
• Older children andadults– Isittoolate?– Ifnot,
• Metacognitiveapproaches
HewittMarch2016 54
Interventionswithsupportingevidence
• Early intervention approaches– EarlyIntensiveBehavioralIntervention
– http://www.lovaas.com/– Pivotalresponse treatment
– http://education.ucsb.edu/autism/prt.html– EnhancedMilieuTeaching
– http://kc.vanderbilt.edu/kidtalk/f iles/presentations/Kaiser_AUCD%20Webinar_2_22_11.pdf– EarlyStartDenverModel
– http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/– DevelopmentalIndividualizedRelationship-based(D.I.R.Floortime)
– http://www.icdl.com/dirFloortime/overview/– SCERTSmodel
– http://www.scerts.com/– PictureExchangeCommunicationSystem
– http://www.pecsusa.com/– HanenMorethanWords
– http://www.hanen.org/Home.aspx– JASP/ER:Jointattention,StructuredPlay,EmotionRegulation
– http://www.ncbi.nlm.nih.gov/pubmed/22965298– http://www.slideshare.net/autismsciencefd/connie-kasariHewittMarch2016 55
2/29/16
10
Jointattentionintervention• Kasari etal.(2007)
– Theory:socialengagementneededforlanguagedevelopmenttoprogressnormally
– Background:numerousstudiesshowdeficitinjointattentioninchildrenwithASD
– Jointattentionisfoundationofsocialengagement,soincreasingitshouldremediateand/orpreventsomeofthesocialandlanguageimpairmentsinASD
– Interventiontrainsparentstoengagechildreninplay-basedjointattentioninteractions
• (some similarity toFloortime, SCERTS)– Finding:increasedjointattentionANDincreasedvocabulary
HewittMarch2016 56
EarlyStartDenverModel
• Behavioral andnaturalistic combination• Developmental focus• Parent training• Relationship-based
– Fosteringsocial-cognitive, emotional, andcommunication development ineverydayhomeenvironment
– Dawson etal.(2010) – RCT showed gainsinIQ,adaptivebehavior, &autism diagnosis atfollow-up(compared totreatment asusual)
HewittMarch2016 57
IssuesininterventionforASDpastearlyyears
• Neurobiological– The longerasystemhasbeendeveloping,theharderitistocreatesystem-widechange• Behavioralproblemsbecomeentrenched• Problem-solvingstylerefinesitself
– Co-morbiddisordersmaybecomemoreacuteinlateryears
– Adolescentchangescancomplicatematters
HewittMarch2016 58
IssuesininterventionforASDpastearlyyears,cont.
• Families/school environments alsodeveloppatterns ofresponding, expectations
• Laterlanguageneeds tapintoweakestareas– Social-emotionalreciprocity– Inferencing– Executivefunctioning– Cognitiveflexibility,creativity
HewittMarch2016 59
InterventionapproachesforschoolagechildrenwithASD
• Theoreticalbases– Behavioral
• Claimsofthepotentialformassive, system-widechangenolongerpertainasinEIBI
• Behavioristsusethesetechniqueswithallages,butEIBItargetsearlydevel.
– Naturalistic• Challengetoidentifymotivatingnaturalcontextsandgetstudentstoengage
• Unclearifsimilar resultscanbeexpectedfromchild-centeredapproachasinyoungerages
– Metacognitive• Typicaleducationalapproach
– IDskill– Explainskill– Practiceskill
• Classicproblemsofgeneralization,maintenance,cognitivereadinessHewittMarch2016 60
ApproachestoImprovingSocialCommunicationinSchoolAgeChildreny in clude vide o mode ling
• Metacognitivepractice– Usessocial skills drills, but supports withdiscussion toassist in raising
awareness• Forhigher functioning, older individuals
– Winner’s social thinkingapproach fallshere» ThinkingaboutYou,ThinkingaboutMe» www.Socialthinking.com
– Social stories• attempt toraisemetacognitiveawarenessofsocial situations
– Social skills curricula• Manymaterialsexist
– Games– Workbooks– Songs
HewittMarch2016 61
2/29/16
11
Meta-cognitiveapproaches,cont.
• Discussingproblemobjectively• Autism SpectrumQuotient Testhttp://www.wired.com/wir ed/arc hive /9.12/a qtest.h tml
• Jackson (2002) “Freaks, Geeks,and Asperger Syndrome”• Myles, Trautman, &Schelvan (2004)
• RecentresearchapplyingcognitivebehavioraltherapytoASD:moresystematicandsophisticateduseofmetacognitiveapproach
• Evidence-based practice in psychology;SLP’s not trained– Though some implementation withf luency disorders
– EvidencethatCBTassistswithanxiety,includingsocialanxiety
• Sungetal. (2011);White etal. (2010);White etal. (2013);Woodetal. (2009)
HewittMarch2016 62
Approaches to ImprovingSocialCommunicationinSchool AgeChildren, cont.
• Modificationofenvironment– AAC– Visual schedulesandotherenvironmental cues– Sensorydiet– Training offamilies,educationalpersonnel,peers
– Training atclassroomor smallgrouplevel–CommunicationLab(Dodge,1998)–JarvisClutch,SocialSpy(Levine,2001)
» (alsoametacognitiveapproach)
HewittMarch2016 63
SocialCommunicationinASD: Challenges
• Problem– Socialskills,pragmatic languageimpairments arehallmarks ofautism spectrum disorders
– Insufficient controlled researchon interventiontechniques
• E.g.,SocialThinkingverypopular,but2015NSPreportexcludeditasanEBP
– Santhanam &Hewitt(2013)• Interviewed 8youngadultswithASD,foundalmostallsawlimitedbenefitfromorneedforintervention,yetallarticulatedfrustrationwithsocialandvocationalsuccess
HewittMarch2016 64
CriticalNeed forSocialCommunication:Outcomes forAdultswithASD
• Lowratesofeducational andvocationalattainment evenincognitively ableadultswith ASD– Nevill &White(2011)– Levy&Perry (2011)
65HewittMarch2016
Adults with ASD:Underserved andUnderemployed
– Shattucketal.(2011),innationalsurvey,foundlowratesofserviceusagepost-highschool(ages19-23)
• 74%had SLPservices in highschool; only 9%didpost high school• Useofall support services dropped substantially
– Shattucketal.(2012),innationalsurvey,foundover50%ofyoungadultswithASDwerenotemployedorinschool
• 12.1%had attended college
“Youth withan ASDhad the lowest ratesof participationinemployment and the highest ratesof no participationcompared with youth inother disability categories” p.1042
66HewittMarch2016
• Survey in Japan foundlower self-reported qualityoflife foradultswith high-functioning ASDthangeneral population– Kamio, Inada &Koyama (2012)
• Howlin et al. (2013)conductedstandardizedsurvey of60adultswithASDwith atleast averageIQ– Only10 ratedas“good orverygood”outcome– 60%ratedas“poor or verypoor” outcome
• Measures focusedonmentalhealth,employment,independentliving,socialrelations
QualityofLifeandASD
67HewittMarch2016
2/29/16
12
PotentialReasonsforPoorOutcomes
• Co-morbid psychiatric disorders such asanxiety&depression; history of peer rejection
• Shtayermman (2007)• White, Ollendick, &Bray (2011)
• Undiagnosed orinsufficiently managed learningdisabilities and/or language impairments
• Lack of appropriate earlyintervention• Latestart• Lackofconsistency, eclecticism• Lackof intensity
• Forhigh-functioni ng individuals, talents andmanystrengthsmaymask significant difficulties
68HewittMarch2016
Legal Changes from Secondary toPost-Secondary
• IDEAforK-12– Freeandappropriatepubliceducation
• ADAforwork andcollege– Reasonableaccommodations– Equalaccess– nomodificationtocurriculumorperformanceexpectations• conceptoflevelingtheplayingfield
69HewittMarch2016
HowSLP’scanhelpimproveoutcomes
• Supportsandinterventionsweoffertargetkeyriskareas– Communication
• Oral and written– Social knowledge, social reasoning, social functioning– Linguistically and academically-related higher-order
cognition• Self-management• Planning• Task analysis and problem-solving• Strategies foracademic success
70HewittMarch2016
Aspects ofASDSupporting CollegeSuccess
• Mayhavestronginterest insubject ofstudy• Relevantspecial talents• Averagetosuperior intellectual ability
– writing,drawing,mathematics
• Committed tofollowing rules• Mayenjoyreading, intellectual pursuit
– Notasdistractedbysociallife…
71HewittMarch2016
Aspects ofASD notsupportingacademicsuccess
• Social– socialthinking, social communication– needforownspace
• Cognitive– Executivefunctioningdeficits
• higherorderplanning• decisionmaking• timemanagement• organization
– Rigidity• diff icultyadapting
– Informationprocessing• diff icultydealingwithcomplexinput• making rapiddecisionsinnewenvironments
• Emotional– anxiety– depression
72HewittMarch2016
ASDand thepost-secondary environment• Collegeexpectations
– Independence• Sample abilities: cannavigate webtolocatesyllabi; canaccess e-mail forletterof accommodations,print,andsharewithprofessor;canmanage aplanneror
calendar– Problem-solving, higherorderplanning,decision-making
• Sampleabilities: canidentifystepsneededtocompleteassignment;candecidehowmuchtimetoallocatetostudyingversusrecreation;canidentifyneedtocontactprofessorandindependentlyf indouthowtodoso,thencarrythatout.
– Multi-tasking• Sample abilities: canlisten tolecture,andview PowerPoint,whiledecidingwhat
notestowritedown,andwritethem,whilescreeningoutbackgrounddistracters– Sensoryefficiency
• Sample abilities: canmanage tosleep andstudyindorm,despitelightingandnoiseissues; candeal withsmells andnoisesincafeteria
– Spatialreasoningandway-finding• Sample abilities: canlocate buildingsonacampusmap; canfolloworalorwrittendirectionstolocatenewplaces andsuccessfully navigate there independently
– Socialabilities• Sampleabilities: isawareofwhether someone isopen to interacting;knowswhat information toshare,when;knowshowtoshift registerfordifferent socialgroups
73HewittMarch2016
2/29/16
13
MoreonSocialAbilities• Socialsuccess: thinkingaboutwhatothersare
thinking,allthetime,andusingthattomakedecisions aboutyourownactions– BasisofWinner(2007)approach.
• Usingthisinformation,inrealtime,topresentoneself positively,getsocialneedsmet– Requires micro-timing– Exhausting!
• Maybeveryunder-developedinmany18yearoldsonthespectrum
74HewittMarch2016
ButifEBPisnotclearforchildren….
• Situation ismuch worseforadults
75HewittMarch2016
BestpracticesforASD:stillrelevantforadults
• Individualized• Breaking downcomplex information, teachingnew skillsstep-by-step
• Repetition• Reducing auditory input/increasing visual input• Making explicit andobviouswhat isinferred andsubtle
• Expectation thatdevelopmental trajectory willnotbe rapid
76HewittMarch2016
Transitionplanning
• Determining thetrue level ofindependenceof the student– Whatsupportsarepresent?– Howdothosecontrastwithwhatisavailableincollege?
• Realism isamust!
– Craftgoalsthattargetareaswheresupportsaremostlikelytobeabsentincollege
• Self-management, higher order planning
77HewittMarch2016
ApproachestointerventionforyoungadultswithASD
• Where aretheneeds?– Startwithassessment
• Basics:– Interview withparents, case history– Interview withstudent
• Probing pragmatics– Double interview (Winner, 2007)
• Executive functioning– FAVRES
• Literacy/residual language impairments– Surprising number of studentshave dif f icultywithcollege level reading comprehension
78HewittMarch2016
Communicationgoalsforcollege• Professionalcommunication:Goalareasfortransition
planning• Making phonecalls independently• E-mail
– Checking it– Courtesy/ responding– Interpreting nuances
» “shesaid‘get it to mewhen youcan’”• Off ice hours• Campus services• Reading a syllabus• Howtowork ingroups
– “That kid is anidiot but Iknow not to tellhim so”
79HewittMarch2016
2/29/16
14
Communicationgoalsforcollege,cont.
• Socialcommunication:Goalareasfortransitionplanning– Livinginthedorm
• Roommates?– Approachingpeople
• How doyouknowwho youcantalkto?• High techcorollary:
– Who can you text
» And howo ften…– Fo l lowon so cial med ia
– Conversation• Topics
– App rop riateness» Erro rs o fq ual i ty
– Man ipu lation» Erro rs o fq uan ti ty
• Partner-focused questions– “The so cial fake”– Recip ro ci ty
80HewittMarch2016
UsingWinner ’sSocialThinkingCurriculum
• Coreconcepts– Teaching socially oriented problem-solving– Step-by-step breakdown of howtounderstand whatothers arethinkingsoyoucan predictwhattheywilldo
– Quote fromfirstyearstudentwith ASD» “It’simpossible toknowwhatanyone is thinkingunless youareamind reader”
• Expected andunexpectedbehaviors• “Thinkingwithyoureyes”—howtoentersocialsituations
• Winner 2007aandbreferences inyourhandout
81HewittMarch2016
Otherstufftothinkabout• Wayfinding
– Manywith ASDhavedifficulty with spatial reasoning;maybemasked if theyareused tosupports
• Clothingchoices– Clothing communicates….
• Vulnerabilitiestoexploitation– Goals forunderstanding when others are inappropriate
• Student Codeof Conductmay help• Videogameaddiction
82HewittMarch2016
Unresolvedlearningdisabilitiesand/ormissingskills
• Higher order reading comprehension• Note taking• Studystrategies• Understanding collegelevelassignments
– “Idon’tknowwheretostart”• Timemanagement
– Usingaplanner– Technologyaids
83HewittMarch2016
Managingco-morbidpsychiatricproblems
• Individuals with ASDathighriskforotherpsychiatric problems– Ifworkingwithapsychiatrist/psychologist,whatsupportsavailable?
– Whatisoncampus?• Oftencampusservicesintendedforshorttermcounseling
– Cantheytaketheirmedicationindependently?• Andwillthey?
84HewittMarch2016
Anxietyanddepression
• Candestroy astudent’s college career– familiesmustbepreparedwithaplan– Studentsneedskillstoidentifyproblemandseekhelp
– Studentswiththisprofilemightconsidera2+2approach,startingatacommunitycollege
85HewittMarch2016
2/29/16
15
CognitiveBehavioralTherapy
• Evidence-based practice formanypsychological problems– Well-documentedaseffectiveforsocialanxietyinASD• SeeHewitt2014forareview
– http://sig1perspectives.pubs.a sha.org /art icle.aspx?ar ticleid =1838333
HewittMarch2016 86
Whose collegecareerisit?
• Student musthaveinternal motivation– College isalow-structuredsituation
• Designedastransitiontoadulthood– Noamount ofemails, phone calls, textsandvisits fromparents cancreate the internal drive in thestudent if it islacking
• Neurobiologyrevisited:– All college students cangetexhausted andstressed– College students with ASDwill oftenbemoreso
» Plunged into stressful context ill-matched to their uniqueprofiles
• -àeverydaycanbeahugechallenge.
87HewittMarch2016
Modeling inASD:Imitation• Imitationabilities
– LackofimitationisaredflagforASDintoddlers– But…superiorimitationabilitiesseeninotherrealms
• Echoedspeech• Savantabilities• “Hyper-imitation”
– SoisimitationimpairedinASD,oractuallysuperior?– Sowden,S.,Koehne,S.,Catmur,C.,Dz iobek,I.andBird,G.(2016),Intactautomaticimitationandtypical
spatialcompatibilityinautismspectrumdisorder:ChallengingtheBrokenMirrorTheory.AutismResearch,9: 292–300.doi: 10.1002/aur.1511
• Automatic imitation actuallysuperior• Sociallymediated imitativebehaviors impaired
– Notbecause imitationability lacking, butbecauseof dif f icultieswithcomplex,social situations
» Individualswithimpairedtheoryof mindfoundtobe“hyper- imitators”(Spengler, Bird,etal., 2010)
HewittMarch2016 88
ModelinginASD:Behavioraltreatments
• Verylargeliterature supports behavioralinterventions for ASD,especially EIBI– Reichow,B.(2012).Overviewofmeta-analysesonearlyintensivebehavioral
interventionforyoungchildrenwithautismspectrumdisorders.JournalofAutismandDevelopmentalDisorders,42(4),512-520.
– Keycomponentsofthistreatmentincludemodeling• Taskanalys is
• Repetition• Reward for correct imitation
HewittMarch2016 89
VisualSupports inASD
• Manyvisualapproaches– PictureExchangeCommunicationSystem– SocialStories– VisualTeaching– VisualSchedules
HewittMarch2016 90
SocialStories• Gray(2000)
– Simplesentences• Specif ic typesof sentences
– Pictures,ifneeded– Tailoredtochild– Specificguidelines:
• Listdesired behaviors,notprohibitedones• Give choices• Use “sometimes” ,“may” , etc.
– Helps decrease rigidity• Plantofadethemover time• More resourcesfromCarolGray:http://www.thegraycenter.org/index.cfm
HewittMarch2016 91
2/29/16
16
Morevisual approaches• Learningtoreademotionalcues
– Softwaregames• E.g.,Mind Reading• http://autismcoach.com/Mind%20Read ing.htm
• Communicatingaboutemotions– Visualcommunicationnotebooks
• Limited evidence foranyofthese, despitepopularity
HewittMarch2016 92
Visualapproaches, cont.
• Schedules, Planners, VisualOrganizers– Rationale
• Decreasesanxietybyincreasingknowledgeofwhattoexpect
• Incorporateslanguagetogowithsituation– Especially if student can read
• Decreasememoryburdensonstudent
HewittMarch2016 93
So,doanyoftheabovework?
• Evidence-basedpracticeforASDandpragmatics– Wearenotthereyet
• Bellini,Peters,Benner&Hopf (2007)– Metaanalysis ofsocial skills training studies forASD
» Little tono effect• Morehopefulresultsfoundinbelowreview:preliminarylowlevelevidenceshowsmodestgainsforsocialskillsgroupandindividualtraining,aswellaspeermodeling:
– Burgess,S.,&Turkstra,L.S.(2006).SocialSkillsInterventionforAdolescentswithAutismSpectrumDisorders:AReviewoftheExperimentalEvidence.EBPBriefs,1(4) ,1-21.
HewittMarch2016 94
SocialStories:Evidencelacking
HewittMarch2016 95
Case example: Social Stories (Gray, 2000)Daneshvar (2006)
Did not f ind social stories ef fect ive in teaching social behaviors to children with ASD
Scattone et al. (2006)Effect ive for 2 of 3 children in small study
Rust & Smith (2006)Review of studies to date found confounds
Other interventions at same t imeDifferent behaviors expected from caregivers
Designs weakGeneralization beyond duration of the study not invest igated
Some withdrawal designs suggest behavior reverts when story withdrawn
So,dosocial storieswork?
• Information isinconclusive• Important toincorporate themwithin amorecomprehensive behavioral plan
• Needtobewell-integrated intochild’senvironment, individualized totheir needs
• Not clearhow long-term theeffectsare
HewittMarch2016 96
Visual teaching strategy
Hewitt March 2016 97
http://www.specialed.us/autism/printinst.htm
2/29/16
17
WhyVisual
• Not necessarily becausevision inandofitselfbetter inASD– Someevidencesuggestsauditoryissues:
• Roth,D.A.E., Muchnik, C.,Shabtai, E., Hildesheimer, M., & Henkin, Y. (2012).Evidence foratypicalauditorybrainstemresponsesinyoungchildrenwithsuspectedautismspectrumdisorders.DevelopmentalMedicine & ChildNeurology,54 (1) ,23-29.
– However,natureofvisualinformationinherentlydifferentthanauditory
HewittMarch2016 98
Visualvs.Auditory
Visual• Persiststhroughtime• Canberepeatedexactly• Canusuallyprocess
separateelements,ifneedbe– E.g.,examining details of
shape orposition
Auditory• Transitory• Forspeech,exactrepetition
onlypossiblewithrecording• Cannoteasilyprocess
separatecomponents
HewittMarch2016 99
VisualSupports forASD
• Visuallyenhanced environments– E.g.,workbins,footprintstoshowwheretogo,TimeTimers
• Written and/or graphic instructions orprompts– E.g.,Red/yellow/green lights
• Visualschedules/visual activityschedules
HewittMarch2016 100
Modeling
• Providing intentionally planned inputdemonstrating somebehavior
• Strict definition involvesdemonstration alone,without instruction orfeedback– Thisishowitisusedinthemostnaturalisticlanguage therapyapproaches
– Modelingplusfeedbackusedinmorestructuredapproaches
HewittMarch2016 101
Staticvs.dynamic input
• Visualschedules/visual activityschedules arestatic– Evidence-basedpracticeforASD
• Knight, V., Sartini, E., & Spriggs, A.D. (2015).Evaluating visual activityschedules as evidence-based practice forindividuals withautism spectrumdisorders. Journalof AutismandDevelopmental Disorders, 45 (1) ,157-178.
– Goodforprovidingunchangingcuesforexpectedsequencesofactivities
– Decreaseneed toauditorypromptsandreminders– Increaseindependence
HewittMarch2016 102
Staticvs.dynamic, cont.
• Problem:– ImitationinASDnotimpairedatbasiclevel– Problemsarisewithcomplex,especiallycomplexsocial,activities
• Dynamicdemonstration– Livedemonstrationshavesameproblemsasauditoryinput• Transitory,hardtoreplicateexactly• ProcessinglimitationsofpersonwithASDmayconflictwithpatienceandexactnessofpersonprovidingmodel
HewittMarch2016 103
2/29/16
18
VideoModelingRationale
– Manybehaviorsarelearnedthoughobservationofothersintheworld
– Videoallowsonetofocusinondesiredbehaviorswithoutoutsidedistractors
– Allowsrepeated, identicalviewingstofocusonspecificdetails
HewittMarch2016 104
Modeling:AnEvidence-BasedPracticeforASD
• National StandardsProject (2015)identifiedmodeling andvideomodeling asevidencebased– http://www.nationalautismcenter.org/national-standards-project/
National AutismCenter (2015).Findings andconclusions: National standards project, phase2.Randolph, MA:Author.
HewittMarch2016 105
VideoModelingSupportintheLiterature:RecentExamples
• Playandplay-basedsocialbehaviors– Boudreau &Harvey,2013;Kourassanis, Jones, &Fienup, 2015;Sani-
Bozkurt &Ozen, 2015• Workplacesupports
– Burke etal. ,2013;Kellems, 2010• Socialcommunication,socialabilities
– Chen, Lee,&Lin, 2016;Hochhauser, Gal,&Weiss, 2015;Kabashi,2013;Mason etal. ,2012;O’Handley, Radley, &Whipple, 2015;Ozerk&Ozerk, 2015;Wilson, 2013a;Wilson 2013b
• Academicskills– MacDonald etal. ,2015;Yakubova, Hughes, &Hornberger, 2015
• Self-help,activitiesofdailyliving– McLay etal. ,2015– Spriggs, Knight, &Sherrow, 2015;
HewittMarch2016 106
However…• Applying rigorous criteria forestablishing anevidence-based practice, McCoyetal.(2016)didNOTfindvideo modeling forsocial skillstohavesufficient evidence– Issues:
• Lackofrigorousparticipantdescription/diagnosis• Failuretoestablishexperimentalcontrol
– Studiesshowedpositiveresults,butwerenotconductedinasufficientlyrigorousmanner,perproceduresadvocatedbyReichow (2011):
HewittMarch2016 107
VideoModeling• Videomodeling
• Models created byothersforclienttowatch– Commercial materials
» E.g.http:/ /www.modelmekids .com/– Some show “Don’ts” as well as “Do’s”– May confuse extremely literal children
• Teacher/clinician-created materials– Adult models
– Peer models
• Materials takenfrommassmedia orsocial media sites– TV, movies , YouTube
» Some great colleagues share resources :• https :/ / jillkuzma.wordpress .com/you tub e-vid eo-li nks -f or-soci al-skills /
• https :/ /www.pinterest.com/dow erassocia tes/video -m odeli ng/
HewittMarch2016 108
Videoselfmodeling• Modelscreatedbyskillfuleditingthatpurporttoshowthe
clientperformingthetargetskill– (Gelbar, Anderson, McCarthy, &Buggey, 2012)
• Theory– Increasedmotivationandattentionwhenmodelresemblesself– Providessupportiveinputofseeingoneselfproducetargetbehavior
– ‘IcandothisbecauseIalreadyhave’
• Hybridapproach• Createmodels, videoclient copying them, playvideo back,haveclient self critique, tryagain
HewittMarch2016 109
2/29/16
19
Creatingyourownvideos:TechnologyConsiderations
• Smart phones, tablets, computers withbuilt-incameras—video iseverywhere.– Easytotake– Easytoedit– Easytodelete?
• Issues toconsider:– Privacy:ifyouuseyourownsmartphone,doyouhavetechnicalabilitytodeleteavideosoitisnotrecoverable?
• Makesure it isnot synced toanycloud apps• Supposedly video deleted from iPad thatyou tookon iPad ispermanently gone ifyoudid notbackitup
– https://discussions.apple.com/thread/3747602?tstart=0
HewittMarch2016 110
Determininggoalsforvideomodeling
• Foryoungerchildren, basedon– Functionalimpact
• Isbehaviorsociallyisolating/imposingabarriertoaccesstocurriculumorotherlifecontexts?
• Degreeofvariationfromthenorm• Isitpotentiallydangerousfortheperson?
– E.g.,lackofknowledge ofappropriate topics maybenuisanceina3rd grader, butharassment ina10th grader
• Caregiverconcern
– Frequency
HewittMarch2016 111
Determininggoalsforvideomodeling,cont.
• Forolder children and adults, all on previous slide stillrelevant, and inaddition:
• Client’s perspective and needs– E.g.,Desiretochange
• I want tocommunicate betterwith myco-workers.– Goodbasis tobegin work
• I amnota smileyperson—it’s artificial and I need tobemyself. – Cannottarget goal nomatter howimpactful fortheclient’s problem.
– Note:Adolescentsmaynothavereadiness,whichmaybeneurological;mayneedmoreexecutivefunctiondevelopmenttohelpwithimpulsecontrolandtakingthelongview
HewittMarch2016 112
Makingvideos
• Short• Simple, with aclear scenario• Repetition• Client practice
– Videothose,asktocompare
HewittMarch2016 113
Privacyandsecurity
• Permission totakevideo?• Permission tokeepvideoforreuse?• Onschool/clinic equipment, isitsecurelystored? Could others accessit?
HewittMarch2016 114
Technicalconsiderations
• Lighting• Background• Audio quality• Editing
– iMovienottoohardtofigureout• Useofavatars,other cutting edgetech
– http://buggeyvsm.net/resources.html
HewittMarch2016 115
2/29/16
20
Groups
• Thecoolfactor– Whenisittoomuchfuntobepractical?
• Establish ground rules– Listofrulesandregs– Visualscheduleforvideomodelingsessions– Consequences
HewittMarch2016 116
Let’stryitout
HewittMarch2016 117
ContactInformation
• LynneHewitt• [email protected]• 419-372-6031
HewittMarch2016 118