Download SpeakerHandouts/buckendorf naturalistic interventions slp 17

Naturalistic Interventions for
Children with Autism
KSHA, 2015
•G. Robert Buckendorf, PhD
Hello Clinic, LLC
•Assistant Clinical Professor, Oregon
Health Science University
•[email protected]
In next slide, look for:
eye gaze
gesture
body orientation
language
kind of play
responsiveness to play partner including
sharing and showing
Why Does Accurate Diagnosis Matter
Explains symptoms/ guilt relief
Course of disorder and co-occurring
conditions
Correct interventions
Communication among professionals and
families
Autism DSM-5
Diagnostic and Statistical Manual-5
Two major clusters of symptoms, not three
Qualifiers added including with or without
intellectual disability and with or without
language disorder; severity (requiring
support, requiring substantial support,
requiring very substantial support)
Autism- diagnostic
criteria; DSM-IV
• Persistent deficits in social communication and
social interaction across contexts, including
deficits in (need all three):
• social-emotional reciprocity
• nonverbal communicative behaviors used for
social interaction
• developing and maintaining relationships
Social-Emotional Reciprocity
Abnormal social approach; failure in the
back and forth of conversation
Reduced sharing of interests, emotions, or
affect
Failure to initiate or respond to social
interactions
Nonverbal Communicative Behaviors
Used for Communication
Poorly integrated verbal and nonverbal
communication
Abnormalities in eye contact and body
language
Total lack or reduced facial expressions and
nonverbal communication
Difficulty in developing, maintaining,
and understanding relationships
Adjusting behavior to suit various social
contexts
Sharing imaginative play or in making
friends
Absence of interest in peers
Restricted, repetitive patterns of behavior,
interests or activities including (need 2)
Stereotyped or repetitive speech, motor movements, or use of
objects (simple motor stereotypies, lining up of toys or flipping
objects, echolalia, idiosyncratic phrases)
Excessive adherence to routines, insistence on sameness, ritualized
patterns of verbal or nonverbal behavior, or excessive resistance to
change (extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greetings rituals, need to take
same route or eats same food every day)
Highly restricted, fixated interests that are abnormal in intensity
or focus (strong attachment to or preoccupations with unusual
objects, excessively circumscribed or perseverative interests)
Hyper or hypo reactivity to sensory input or unusual interest in
sensory aspects of environment (apparent indifference to pain or
temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with
lights or movement
Alternative Diagnoses
Intellectual disability (Mental Retardation)
Language disorder
Reactive attachment disorder (History of
pathogenic care)
Anxiety disorders
Mood disorders
Attention deficit disorder
Effective Interventions- National
Research Council, 2001(NRC)
Start early and intensive (every day, all day)
Always work on engaging the child- looking,
vocalizing, showing, modeling, arranging
Activities that are developmentally
appropriate; target functional and
spontaneous language
Goal driven and track changes (i.e., initiate
and respond to joint attention, coordinate
gesture and vocalization)
Types of Treatment
McCoy, 2013
Family support
Educational-behavioral interventions (target
core symptoms)
Treatment for associated medical problems
Medications to target behaviors
Complimentary and alternative medicine
Treatment
Goals:
Minimize the core features and associated
deficits
Maximize functional independence and
quality of life
Alleviate family distress
What do we teach?
Mastery of skills that follow a developmental
sequence
Functional perspective- skills that allow the
child to participate more fully in community
settings; real world skills; adolescents
Focus on skills needed in future settingspreacademics
Challenging Behaviors: General Approaches
Behavior is communication
Challenging behavior may reflect a common
medical problem
Medications are never used alone; it should be
part of a comprehensive, multidisciplinary
treatment approach
Evidence Based Practice
Team is composed of
Parents- priorities, concerns, knowledge
of child; listen to clinician experts
Clinician- expertise and clinical judgment,
knowledge, practice based evidence; be
willing to change and learn; challenge
assumptions
Research findings- what is effective
Purpose of Intervention
Eliminate underlying cause of disorder
(hearing aids, soft palate surgery or
appliance
Teach compensatory strategies (pictures or
sign to communicate if unable to speak;
control rate if stutters)
Modify the disorder by teahing specific
behaviors (language, stuttering,
engagement, eye gaze
Core Communication
Deficits- NRC
Joint attention (“Keys of the Kingdom”)Coordinating attention between people and an
object- point to share, difficulty attending to
a social partner, gaze shift, sharing affect
with another, follow gaze or point, showing.
Lack of initiating JA discriminated ASD from
all other disorders.
Use of symbols- words, gestures, functional
use of objects, symbolic play.
Communicative Intent
• Child becomes intentional and interactive;
purposeful, about 6 mos.
• Begins with caregivers reading non-purposeful
behaviors as purposeful (smile, coo, cries for
distress, follows gaze, vocalizes)
• The child tells you what they want in a variety
of ways; eventually request for information,
comments, acknowledgement, greeting,
attention getting
Initiation
Child must initiate or take the lead
Set up environment so child initiates; at the
beginning it will be a glance or reach toward
Respond quickly to that initiation, no matter
how subtle.
The key is quick response to the child’s
initiations
Reciprocity
• Joint Engagement
• Shared attention
• Turn take (paying attention to each other)
• Circles of communication
• Not object focused but other focused
Applied Behavioral Analysis
Amy Donaldson, 2013
Measurable tasks to determine if
interventions are effective
A- Antecedent (stimulus) “what is this?”
B- Behavior (what person does in response
to behavior (“it’s a car”)
C- Consequence (reinforcer which shapes
the behavior “great job”)
Behavior has to be measurable
Intervention Domains
Communication
Social interaction
Play
Motor
Cognition
Adaptive behaviors
ESDM Treatment Model
Teaching strategies that target reciprocal
turns driven by affect, use of real-life
materials and activities, teaching
caregivers to be responsive and sensitive to
child cues, and focus on both verbal and
gestural communication. Uses
developmental curriculum that focuses on
language, social skills, cognition, play, fine
and gross motor skills, and personal
independence at four levels.
Strategies from ABA
Capturing attention
Antecedent-Behavior-Consequence
Prompt desired behaviors
Manage consequences
Fade prompts
Shape behaviors
Chaining behaviors
Functional Assessment
Strategies from PRT
Motivation through: Child Choice and follow
turn taking; lead and follow
Reinforcing all attempts and reinforcer with
direct relationship to behavior
Interspersing maintenance tasks
Response to multiple cues by vary
antecedents, set up stimuli with multiple cues
teach children to give same behavior with a
variety of antecedents
Specific ESDM
Strategies
Adults optimize child’s affect
Adults use positive affect
Turn-taking and engagement throughout
Adults respond sensitively to child’s cues
Multiple and varied communicative
opportunities occur
Elaboration of activities- multiple materials
and many activities from many domains
Parent-Training Program (2010)
Ingersol and Dvortcsak
Follow your child’s lead
Imitate your child
Be animated
Model and expand language
Playful obstruction
Turn taking and modeling and expanding
play
Communicative Temptations
Responsive Teaching (McDonald &
Mahoney) responsiveteaching.org
• Parent mediated; uses strategies that help children
use pivotal behaviors (cognition, communication,
social emotional functioning, motivation-interest
and enjoyment); teach parents to be proactively
responsive to their children and shift lead to child;
parents can be effective.
• Reciprocity- joint activity and routines; shared
power
• Contingency- timing
• Shared control- moderate direction
• Affect- warmth, enjoyment
• Match- developmental, interests of child
Specific
strategies
• Reciprocity
–
Engagement; be physically available, play frequently together;
expect my child to interact (versus learned helplessness)
–
Balance; “Take one turn and wait”, play with sounds back and
forth, communicate less so my child has to communicate more;
child learns to interact with “someone” instead of using the parent
as a tool or ignoring them; “eyes” are very important so work at
eye level
• Contingency
–Awareness; take my child’s perspective, be
sensitive to my child’s state
–Timing; “respond quickly to my child’s cries
and little behaviors”, discipline promptly and
comfort
–Intent; respond to unintentional behaviors as if
they were meaningful, accept incorrect
articulations and just respond to intent
–Frequency; respond throughout the day and with
multiple caregivers
• Affect
– Animation; wait with anticipation, respond to child in
playful ways, be more interesting than my child’s
distractions, use nonverbal gestures and intonation
– Enjoyment; playful partner, interact for fun, turn
routines into games, repeat activities my child enjoys
– Warmth; be physical and gentle, respond with
affection to child’s cries, comfort child
– Acceptance; value what child is doing, treat my child’s
fears as meaningful , accept what my child does, talk
about funny and novel things my child is doing
• Shared Control
–Moderate direction; communicate without asking
directions, imitate child’s actions, give my child
frequent opportunities to make choices
–Facilitation; expand to show child the next
developmental step, expand their actions or
utterances, wait silently for a more mature
response, change the environment
Ingersoll & Dvortsak
Always- follow lead, imitate child, model
and expand language, be animated
Mostly- arrange environment, playfully
obstruct, control access
Sometimes- prompt to increase complexity
of child’s response
Importance of Teaching Parents
Ingersoll & Dvortsak, 2003)
Parents can learn to effectively intervene
Parents spend the most time with their
children; provide intervention throughout
the day
Reduces parent stress and increases their
feelings of competence (Koegel et al, 1982)
Family Goals
Consistently respond to his behaviors
quickly- teaches him that he does
something and then something happens.
Help him continually be engaged with you.
When playing with or working with him,
stop in the middle and wait to let him lead
you.
Identify specific places where activities
occur. Then the child can request
purposefully by going to that area, then
taking parent there, then using an object
symbol to talk about the activity.
Begin to build object-symbol vocabulary of
tangle object-symbols that relate to child’s
basic needs.
website for objects is objectsymbol.com
Parent-Training Program (2010)
Ingersol and Dvortcsak
Follow your child’s lead
Imitate your child
Be animated
Model and expand language
Playful obstruction
Turn taking and modeling and expanding
play
Communicative Temptations
the old days
change
kisses
the lie
I am special
Other References
Educating Children with Autism. (2001).
National Research Council.
Management of Children with Autism
Spectrum Disorders, Pediatrics. Oct., 2007.
Rogers, S. & Dawson, G. (2010) Early Start
Denver Model for Young Children. Guilford
Press: New York.
Websites
firstsigns.org (videos, diagnosis, treatment)
autismspeaks.org (parent advocates,
research, 100 day kit, autism and
medication; safe use kit)
www.helpautismnow.com/international.ht
ml