Autism Spectrum Disorders:

Research findings and treatment implications

Center for Autism and Related Disorders, Inc

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

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 IVAutistic 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

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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)

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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

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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

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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

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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

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Level of SeveritySeverity Level for ASD Social Communication Restricted interests &

repetitive behaviors

Level 1: Requiring Support

Without support, some significant deficits in social communication

Significant interference in at least one context

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

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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

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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

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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!

Teach New LearningPatterns

Genetic Predisposition

Physical ConditionsOxidative Stress Decreased Methylation

Immune Dysfunction GI Inflammation

Brain DisordersHypoperfusion

Hypo and Hyper sensitivity to stimuliDifferent Learning Patterns

Behavioral SymptomsDelayed Language

Delayed Social SkillsStereotypy

AUTISMMetals

Pesticides BisphenolAAntibiotics

Minimize ExposureTo Toxins

Treat the Underlying

Medical Disorders

Identify Sensory Issues

Reduce/Eliminate Symptoms

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 sensesHow 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 ConstancyMatch 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

to

Second Picture

2.

First Picture

to

Second Picture

3.

First Picture

to

Second Picture

Visual Figure-Ground Discrimination

1.

How many times is the number 8 in the above picture?

10 times 7 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 issuesDevelopmental 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

Autism leads to Anxiety

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 Group:

N=19

Control Group 2:

N=20

Control Group 1:

N=20

40 hours/wk 3 yrs

10 hours/wk3 yrs

10 hours/wkUCLA/NPI

3 yrs

47% Recovered!

2% Recovered

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 ABAResults:

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 ABAResults:

Average IQ: 57% Success in unsupported regular

education : 28% Non-impaired on the Vineland adaptive

behavior composite: 38%

Replication in Norway2 years of ABAResults:

Average IQ: 7/13 = 54% Average score on Aechenbach

CBC: 4/13 = 31%

Replication in England25 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 EastResults:

Scoring in non-ASD range on ADOS after treatment: 4/19 = 21%

Whole province of Ontario, CanadaFree ABA for all young children with autism332 children71% made significant gains11% achieved functioning in the average rangePoor 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 outcomeN = 245More treatment = more gainsPublished in Research in Autism Spectrum Disorders (2009)

Recovery from Autism

Retrospective analysis of charts in 38 cases of recovery following ABA treatmentIn-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 TreatmentSensory

InterventionsDevelop and

Regulatesensory input ability

Behavioral Interventions

Teach new learning patters

Generalize to daily living

Medical InterventionsEliminate Triggers

Stabilize underlying cause

Achieve health

A healthy child feels better, sleeps better

and can learn better!!

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

63 boys 16 girls

79 children

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

More than 25 hours/week

44 children

Low Intensity

Less than 25 hours/week

35 children

Matched on age, IQ, language, adaptive behavior

Results: Outcome 1996Mean Client IQ Pre- and Post-Treatment

70

75

80

85

90

95

100

1 2

IQ S

tan

da

rd S

co

re High Intensity

Low Intensity

Pre-Treatment Post Treatment

Mean Adaptive Functioning Pre- and Post-Treatment

60

65

70

75

80

85

90

95

100

1 2

Vin

elan

d S

tand

ard

Sco

re

High Intensity

Low Intensity

Pre-Treatment Post Treatment

WPPSI: Pre- & Post-ABA Early Intervention

0

10

20

30

40

50

60

70

80

90

100

110

120

130

20 22 27 29 29 30 30 31 31 31 32 34 38

Average Therapy Hours Per Week

Intel

ligen

ce Q

uotie

nt

Pre-Test

Post-Test

Normal Cognitive Functioning

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: AutismIntake: 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.

DR

0

50

100

150

200

250

Nov-03 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04

Months

Ne

w S

kil

ls p

er

Mo

nth

ABA + IgG Allergy

Elimination Diet +

Feingold Diet +

Rotation diet

ABA + Specific Carbohydrate Diet

D.R.: New Skills per month

DR

0

100

200

300

400

500

600

700

800

Nov Dec Jan Feb Mar April May June

Months

Fre

qu

en

cy

of

Ste

reo

typ

y p

er

Mo

nth

Visual SSB Verbal SSB Oral Motor SSB Tactile SSB

ABA + IgG Allergy

Elimination Diet +

Feingold Diet +

Rotation diet

ABA + Specific Carbohydrate Diet

D.R.: Stereotypy per month

DR

0

10

20

30

40

50

60

70

80

90

100

Nov Dec Jan Feb Mar April May June

Months

ABA + IgG Allergy

Elimination Diet +

Feingold Diet +

Rotation diet

ABA + Specific Carbohydrate Diet F

req

ue

nc

y o

f A

gg

res

sio

n p

er

Mo

nth

D.R.: Aggression per month

EmmaDiagnosis: Asperger’s SyndromeIntake: 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

0

1

2

3

4

5

6

7

April May June July Aug Sept Oct Nov Dec

Months

Fre

qu

en

cy

pe

r S

es

sio

n

Tantrums Non-Compliance Ritual SSB

ABA + Lexapro

ABA + ProDHA + Coromega

ABA

Emma: Challenging Behaviors per month

Emma

0

20

40

60

80

100

120

Mar 04 April 04 May 04 June 04 July 04 Aug 04 Sept 04 Oct 04 Nov 04 Dec 04

Months

Ne

w S

kil

ls p

er

Mo

nth

ABA + Lexapro

ABA + ProDHA + Coromega

ABA

Emma: New Skills per month

A. D. Diagnosis: AutismIntake: Age: 2.11 Deficits: had 3-4 word utterances but no spontaneous language, self-

isolated 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 self-stimulatory behaviors present. Normal range on all exit testing (IQ, language, TOM, EF)

AD

0

2

4

6

8

10

12

14

May

June

July

Aug

Sep

t

Oct

Nov

Dec Jan

Feb

Mar

ch

Apr

il

May

June

Month

Fre

qu

en

cy

pe

r H

ou

r

Elopement Fidgeting LeaningRunning Grabbing Screaming

ABAABA +

Antifungal + Chelation

A.D.: Challenging Behaviors per month

AD

0

50

100

150

200

250

June

July

Aug

Sep

t

Oct

Nov

Dec Jan

Feb

Mar

ch

Apr

il

May

June

Month

Ne

w S

kill

s p

er

Mo

nth

ABAABA +

Antifungal + Chelation

A.D.: New Skills per month

What do we learn from these Case Studies?

A variety of medical interventions worked for these childrenEach child benefited from a different type of interventionAutism 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 consequencesWhat 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 InstructionGive rewards for these

Behavior ManagementRemove 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 wantsHe 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 Remove

positive

Behavior Behavior

negative

Behavior Behavior

+ Reinforcement

- Reinforcement

Response CostExtinction

Punishment

How do we change behavior?

Change behavior by changing the antecedent or the consequence or both!

Todd wants toy Todd hits sibling Todd gets toyTodd does not get toy

Teach Todd to ask when he

wants toyTodd will not hit

sibling

Todd will not hit sibling

Mark wants attention

Mark cries and tantrums

Mark gets attention

Mark doesn’t get attention

Teach Mark to do something appropriate

Mark does something

appropriate

Mark gets attention

Jon hates school

Jon screams Jon is sent home

Jon is not sent home

Jon learns skills so helikes school

Jon will not scream

Step 1: Identifying what the child wants to communicateStep 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 changeIdentify 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 behaviorHow?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 InstructionGive rewards for these

Behavior ManagementRemove rewards for these

The CARD Curriculum

Language Adaptive Motor Academic

Play Cognitive

Executive Functions

Social

The CARD Curriculum

0-11 mos.Body PartsFollowing InstructionsGesturesMaking RequestsPeopleSound DiscriminationVerbal ImitationYes/No

1:0 – 1:11 yrs.ActionsAsking for InformationCategories

Language

ChoicesFast MappingFunctionsObjectsOppositesPrepositionsPronouns

2:0-2:11 yrs.AdverbsAttribute-ObjectConditionalityDeliver a MessageFeaturesGenderI Have/ISee

Listen to/Tell a StoryLocationsNegationPluralsRecalling EventsSound Speed & DurationSyllable SegmentationWh-Discrimination

3:0-3:11 yrs.Minimal PairsSame/DifferentSequencesSound Changes

Statement-Statement

4:0-4:11 yrs.Describe by Category/Feature/

FunctionPhonic Same/ DifferentStatement- QuestionWhat Goes With

5:0-5:11 yrs.Observational LearningSyntax

By Emerging Age and Verbal Operant:

Mixed Operants

Play Curriculum PlayDomains

Electronic Play

Beginning Play

Interactive Play

PretendPlay

Constructive Play

Sensorimotor PlayTask Completion Play

Initiating and Sustaining Play

Early Social GamesRead-to-Me Books & Nursery Rhymes

Music and MovementTreasure Hunt

Card and Board GamesLocomotor Play

Peer Play

Functional Pretend PlaySymbolic PlayImaginary Play

Sociodramatic Play

Block ImitationStructure Building

Sand and Water ConstructionsClay Constructions

Arts and Crafts

Audio and Video PlayComputer PlayVideo Games

Interactive Play: Nursery Rhymes

Adaptive CurriculumAdaptive

DomesticPet Care

Setting & Clearing TableTelephone Skills

TidyingMeal Preparation

CleaningGardeningLaundry

School Backpack PrepMaking a Bed

PersonalFeedingToileting

UndressingUnfastening

DressingPreventing Spread of Germs

BathingFasteningTeeth CareHair CareNail Care

Health Care

Motor CurriculumMotor

Gross

Fine

Oral

Visual

The CARD Curriculum School Skills

MathNumber Concepts

Rote CountingReading Numerals

Numeral ComprehensionOrdinal Position

Numerals in SequenceAddition

SubtractionAdvanced Counting

MoneyTime

Language Arts 1Reading

Visual Discrimination of SymbolsReciting AlphabetUppercase LettersLowercase LettersWord Recognition

Reading OrallyReading Comprehension

Book TopographyStory Comprehension

Story SummarizingText Comprehension

Language Arts 2Manuscript Writing

Printing SymbolsPersonal Data

Lowercase LettersUppercase Letters

Letters in SequenceLetters Dictated

Simple SentencesQuality of Printing

Physical EducationScience

HistorySocial Studies

NonAcademicSkills

The CARD Curriculum

Cognition: Meta-cognition: Identifying your own … Social Cognition: Inferring others’…

EmotionsThoughts

Knowledge

Desires

Beliefs

Intentions

Cognition

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 SocialCognitive Development

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

Cognition Curriculum

13 Lessons Physical States

Emotions

Cause & Effect

SensesSensory

Perspective Taking

Desires

Preferences

Cognition

Understanding other perspectives

Social Skills CurriculumSocial Skills

Social Skills

Non-VocalSocial

Behavior

SocialLangua

ge

Social Interacti

onSelf Estee

m

Social Context

Social Rules

GroupRelated

Skills

Absurdities

Group Related SkillsResponding in Unison

Group Discussion

Non-Vocal Social BehaviorEye Contact

Non-Vocal ImitationBody Language & Facial Expressions

Gestures to Regulate Social Interaction

Social LanguageGreetings and Salutations

Social ID QuestionsProsody

Regulating OthersConversational Audience

Physical Context of ConversationListening to Conversation

Initiating ConversationJoining Conversation

Maintaining ConversationRepairing Conversation

Transitioning Topics of ConversationEnding Conversation

Social InteractionApologizing

AssertivenessCompliments

Cooperation & NegotiationGaining Attention

IntroductionsLevels of Friendship

Sharing & Turn Taking Lending & BorrowingSelf Esteem

Dealing with ConflictPositive Self-Statements

Winning & Losing Constructive Criticism

Social ContextResponding to Social Cues

Learning Through Observation

Social RulesCompliance

Following RulesCommunity Rules

Politeness & Manners

AbsurditiesFigures of SpeechHumor and JokesWhat’s Wrong?

Responding to Social Cues

The CARD Curriculum

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 FunctionsWhat is Executive Function?

Executive Functions Curriculum

Executive Functions

Planning

Meta-CognitivePlanning

Inhibition Flexibility

Attention

Memory

EF

Flexibility/Set-Shifting

Non-Social,Social,

Social –Cognitive,Situational

AttentionSocial Orienting,Joint Attention,

Sustained, Divided, & Alternating Attention,Determining Saliency,Depth of Processing,

Paraphrasing,Task Persistence

MemoryAssociative,

Visual, Spatial,Auditory, Episodic,

Working

InhibitionWaiting,

Physical / Motor,Vocal,

Pencil / Paper

Problem

Solving

Problem Solving

Non-Social,Social

PlanningTask / Social

Goal Setting, Previewing,Task Initiation,

Monitoring Progress, Time Management,

Organizing Materials, Using a Planner, Self-Organization

Meta-CognitionMeta-cognitive Planning,

Self-Evaluation, Meta-memory, Self-Monitoring of Attention,

Emotions, Reinforcement Control,Study Skills, & Flexibility

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

0

10

20

30

40

Year1

Year2

Year3

Year4

Allocation of Hours

Home-based School-based

A 4 year progressionYear 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)

0

10

20

30

40

Year1

Year2

Year3

Year4

Allocation of Hours

Home-based School-based

A 4 year progressionYear 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

0

10

20

30

40

Year1

Year2

Year3

Year4

Allocation of Hours

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

0

10

20

30

40

Year1

Year2

Year3

Year4

Allocation of Hours

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