Transcript Siegel: ABA Placement - Seattle University School of Law

What Is An ABA Placement?
Seattle University School of Law
Administrative Law Judge Training
October 19, 2011
Bryna Siegel, Ph.D.
Director, Autism Clinic
Co-Director, Autism Neurodevelopment Center
[email protected]
Professor, Child & Adolescent Psychiatry
University of California, San Francisco
Today’s Topics
What has applied behavior analysis
contributed to the treatment of autism?
 How and when do we use it?
 Where does ABA ‘fit’ with developmental
considerations for treatment?
 How do we integrate approaches to ‘cover
all bases’ in defining ‘appropriate
placement’?
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[email protected]
Themes in ABA Literature on Autism
Treatment
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Efficacy of behavioral methods (ABA)
Individualization (ABA)
Intensity (ABA)
Natural environment as teaching milieu (PRT)
Parents/ home/ outside world’s role in
acquisition & generalization (NET)
[email protected]
A Brief History of ABA and Autism
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Pavlov
Skinner: Learning in animals worked
in humans too
Lovaas at UCLA uses ABA for severe SIBs
Lovaas uses ABA to teach ‘positive’ behavior,
not just to extinguish ‘negative’ behavior.
Lovaas’s curriculum content neither
developmental or autism-specific, but…
Introduces intensity, data-based trials & high
mastery levels; these are validated and reified.
[email protected]
Applied Behavior Analysis (ABA) and
the Culture of Autism Treatment
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ABA has become most widely-available one-toone treatment modality for ASDs
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One-to-one complements heterogeneity of ASDs
Potential for highest intensity
ABA has become highly influential in classroom
practices too:
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Mandate for data-driven instructional practices
Need for functional behavioral analyses of behavior
incompatible with instruction
[email protected]
What Have We Learned About ABA
and ASDs in the Last 20 Years?
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ABA can be effective at home and in schools
Behavioral principles have been applied with
different emphases:
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Performing: Discrete trial training (DTT)
Requesting: Pivotal response training (PRT)
Adapting: Natural environment training (NET)
Remaining Challenges:
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Motivation especially social motivation
Developmental appropriateness of curriculum
Generalization of objectives of learning
[email protected]
Concept of the Autism Treatment Toolbox
Selecting the Right Tool for the Job
ABA
and the Autism Treatment Toolbox
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What does autism treatment need to target?
What does ABA target most specifically?
What does ABA leave unaddressed?
How do you fill an autism treatment ‘toolbox’:
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for a particular child, or
for a particular age group, or
for a particular sub-group of children with ASDs?
What tools does ABA give us?
[email protected]
An Example: ABA
for Low Functioning Autism (LFA)?
LFA:
NV/ minimally verbal, PIQ < 50, verbal lower
 Non-linear effect of # hrs of tx
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More is not necessarily better if LFA
Hi intensity (≥ 25 hr./wk)~ low intensity (≤ 20 hr./wk)
Best ABA outcomes:
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NVVerbal in 1st 3 m. of tx (per Lovaas)= nonresponders
Low level of behavior incompatible w/ instruction
[email protected]
Implementation of ABA Methods as a
Function of Placement
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When should treatment be given in a natural
environment?
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Can treatment be delivered in an inclusive setting?
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Typically developing peers predominate?
Can treatment be delivered in an integrated
setting?
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Home? Child care?
Designed for typical and atypically developing children
both?
Does treatment motivate child to self-initiate?
[email protected]
The Importance of Integrating ABA
Methods with Developmental
Considerations
(so it’s not dog training….)
IACAPAP Beijing 2010
[email protected]
What Is the Developmental-Behavioral
Approach?
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Establish curriculum content based on
developmental level/ ‘what comes next’.
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Uses behavioral methodology to teach
developmentally-based curriculum.
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Enhancing motivation by differentially rewarding
self-initiative in learning
[email protected]
Why It’s Important to Include a
‘Developmental’ Perspective
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The brain matures in a fixed sequence,
supporting behavior emerging from increasingly
complex and integrated neural capacities.
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Behavioral development has a fixed sequence
tied to that neural development.
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Children may learn at different rates & ways, but
the ordered sequence for a solid foundation.
[email protected]
Why is it Important to Include a
Behavioral Perspective?
Empirical efficacy of behavioral methods
 Flexibility for individualization
 Ability to control intensity
 Natural environment as teaching milieu
(PRT)
 Parents/ home/ outside world’s role in
acquisition & generalization (NET)
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[email protected]
An Example of Curriculum that is
Developmental and Behavioral
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Based on where the child is developmentally
(e.g. 18 month receptive language—teach the
next set of skills—moving from MLU=1 to
MLU=2).
Calibrate growth trajectory based on learning
history and assessment observations and
results; re-calibrate trajectory annually before
drafting IEP goals.
Do teach using validated behavioral principles.
[email protected]
Another Example of Curriculum that is
Developmental and Behavioral
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Purely Behavioral/ Not Developmental:
Learning ‘stand-up/ sit down’ before ‘mama and
dada.’
Changing the content to be developmental:
Teaching ‘horizontally’, not ‘vertically’: 10
barnyard animals versus 10 faces of mommy
Integrating Developmental and Behavioral:
Keeping the ABA teaching method and pairing it
with a developmental curriculum.
[email protected]
How Have These Considerations Been
Reified in National Standards?
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National Research Council of Nat. Acad. Of
Sciences (2001)
Part C of IDEIA (2004)
Div. of Early Childhood/ Council on Exceptional
Children (2005)
Nat. Assn. for Ed. of Young Children (2009)
[email protected]
‘Active Ingredients’: Intensity
Candidates include:
 Use of 1:1 ?
 # Hours/ Week?
 # Trials?
 % Accurate Responses?
 Level of prompting needed for response?
[email protected]
‘Active Ingredients’:
Developmentally-Appropriate
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Appropriate for Chronological Age?
Appropriate for Developmental ‘Age’?
Developmentally-sequenced?
Comports with developmental ‘morphology’?
(e.g., Language: # of single words before
phrases)
[email protected]
‘Active Ingredients’:
Addresses Social Deficits
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Establishes theory of mind
Establishes joint attention
Establishes instrumental attention-seeking
Establishes expressive attention-sharing
Promotes imitative learning
[email protected]
The Role of Diagnostic and PsychoEducational Assessment in
Formulating a DevelopmentalBehavioral Plan
[email protected]
The Importance of Convergent Validity
in Differential Diagnosis
Informant:
Parent
Structure
(Structured)
Criterion Based
Structure
(Unstructured)
Play-Based
Informant:
Child
AUTISM
DIAGNOSIS
Setting:
(Natural)
Home
Data Collection:
Observe
Data Collection:
Interview
Setting:
School/Clinic
[email protected]
Let’s Just Treat What’s Wrong
Importance (or Not) of Diagnosis
 Identifying Learning Processes
 Identification of What Needs to be
Learned
 Figuring Out How to Teach so the Child
becomes an Independent Learner
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[email protected]
Accounting for Responder
Characteristics in an Educational
Plan
What is A ‘Responder Characteristic?’
Specific ‘Autistic Learning Disabilities’
 Developmental Level
 Language Level
 Maladaptive Behaviors
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[email protected]
(Behavioral) Goals Should Be
Predicated on Developmental
Trajectory
Diagnosis can change
 Degree of cognitive impairment can change
 Language competencies can change
 Changes affect treatment plans
 Changes affect prognostic expectations
 Re-examining goals in light of developmental
trajectory
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[email protected]
The Autistic Learning Disabilities /
Autistic Learning Styles Approach
Siegel B (2010). ‘Reconceptualizing Autistic
Spectrum Disorders as Autism-Specific Learning
Disabilities and Learning Styles’
in T Millon, Krueger, & Simonsen (Eds) Contemporary
Directions in Psychopathology, New York: Guilford
Publications
Autistic Learning Styles Defined:
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Autistic learning styles are intact functions
automatically being deployed to
compensate for impaired systems
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By looking for autistic learning styles, we
discover what works and can make more
use of those intact systems (improving on
success)
[email protected]
What’s an Autistic Learning Style?
ALD + Intact Abilities = ALS
Defined by Matrix of Ability and Disability:
What the child can’t do (ALD) plus what the child can
do = autistic learning style (ALS)
What the Child Does Well Shows Us:
How to ‘deconstruct’ ‘symptoms’ into what works &
what doesn’t (e.g., Echolalia)
Compensatory strategies that are autism-specific
(e.g., VAC vs ASL)
Processing modality ‘substitution’ (e.g., Hearing for
blind vs visual memory for ASD)
[email protected]
Matrix of Ability and Disability
Examples:
Auditory Processing & Visual Memory
Intact Abilities
Impaired Functions
Auditory memory
Slow
auditory
speed
Low
language
Visual
memory
Echolalia
with low
comprehension
Insists on
routines
comprehension
[email protected]
Autistic Learning Styles (ALSs)
Related to Memory
Verbal Intelligence-Related
 Good Auditory Memory without ‘Parsing’
(Memorizes songs, videos or books without
understanding full meaning)
Performance Intelligence-Related
 Good Procedural Memory (Prefers Routines)
(Anticipates exact sequence of events leading to
desired outcomes)
[email protected]
Autistic Learning Styles (ALSs)
Related to Motivation
Verbal Intelligence-Related
 Better use of language when requesting
than commenting
Performance Intelligence-Related
 Good visual-motor-spatial ability without
need for semantic supports
(Does puzzles backward or upside down, draws
from ‘photographic’ memory)
[email protected]
The ALS/ALD Approach:
A New Heuristic
ALS = ‘Autistic Learning Styles’
ALD = ‘Autistic Learning Disabilities’
The ALS/ ALD heuristic can be used to classify
autistic alterations in Perception, Cognition,
Information-Processing, Motivation &
Expression
[email protected]
Autistic Learning Disabilities:
How Social Deficits Affect Learning
Lack of socio-emotional reciprocity=
Lack of desire to please others
Low response to social reinforcers
Lacks concern re: effect on others
Lack of awareness of others=
Motive to please self is foremost
Instrumental learning style
Why
Should
I
Care?
Lack of social imitation=
Low “incidental” learning via copying others
No drive to follow group norms
[email protected]
Autistic Learning Disabilities:
How Non-Verbal Communication
Deficits Affect Learning
Low comprehension of facial/ vocal cues:
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Smiles, frown, more subtle facial affect
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Tone of voice to mark affective/ semantic
meaning
Ignores gestures that are the ‘first’ language:
 Gaze toward topic of conversation
 Point to initiate joint attention to topic
Does not signal comprehension, intentions feelings
[email protected]
Autistic Learning Disabilities:
How Verbal Communication
Deficits Affect Learning
Receptive Language
 Signal : noise problem for verbal ‘signal’
 Language processing with poor ‘parsing’
 Overly literal/ concrete, limited generalization
Expressive Language
 Without ‘theory of mind’, no drive to ‘share’ ideas
 Without instrumental motive, no drive to express
 Oral-motor apraxia synergistic w/ low expressive
drive
[email protected]
Autistic Learning Disabilities:
How Play and Exploration
Deficits Affect Learning
Lack of imagination in play=
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No consolidation of experience via play
linking action and language
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No symbolic actions to link to language to
abstract thinking
Stereotyped and repetitive interests=
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Averse to novelty/ low curiosity
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Limited learning through exploration
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Repetitive interests = mental ‘down time’
[email protected]
‘Active Ingredients’ of ABA
Methodology & the ALD/ALS Model
ABA Approaches (DTT/ PRT/ NET)
SOCIAL INTERACTION
Low Response to Social
Reward
Infrequent Social Reference
or Joint Attention
Likely Benefits
Yes
(via paired association)
No
(attention directed to stimulus materials)
Low Drive for Peer
Affiliation
No
(object or teacher models)
Limited Modeling or
Imitation
Yes
(via forward/ backward chaining)
[email protected]
ABA Approaches (DTT/ PRT/ NET)
COMMUNICATION
Poor Comprehension/ Limited
Para-Linguistics
Likely Benefits
Partial
(Rotely- taught/ non-generative)
Slow Auditory Processing
Speed, Poor Parsing
Partial
(Telegraphic Speech)
Preference for Visual over
Auditory Modalities
Yes
(Use of Visuals & Procedures)
Theory of Mind/ PerspectiveTaking
No
(Reliance of Direct Learning)
[email protected]
ABA Approaches (DTT/ PRT/ NET)
ORGANIZING INFORMATION
Lack of Representation
Capacity (Imagination)
Preference for Repetition
over Novelty
Sensory Modulation
Difficulties
Primary Benefits
Partial
(Rotely- taught/ non-generative)
Yes
(adult-direction)
Yes
(de-sensitization)
[email protected]
ABA Approaches in the Context of
Group vs Individual Treatments
Approaches
Adult-Led
Child-Led
 Discrete
Trial
 SCERTS
Approaches
to Autism
Treatment
Training
 Floor-Time/ DIR
One-to-One
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Pivotal Response
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Relationship
Treatments
Training/ NET
Development
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GroupBased
Treatments
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Incidental Teaching
Special
Education
TEACCH
Denver Model
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Interaction (RDI)
Hanen
General
Education
Inclusion/
Mainstreaming
RSP/DIS Supports
Sunnyvale 3-22-10
[email protected]
Autistic Learning Disabilities and the
Methods that Address Them
Or When to Use ABA and When to Reach
for a Different Tool
Area of
Autistic Learning
Disability
One-to-One
Adult-Led
(ABA-DTT/
PRT/ NET)
SOCIAL
INTERACTION
Low Response to
Social Reward
Infrequent Social
Reference or Joint
Attention
Low Drive for
Peer Affiliation
Limited Modeling
Sunnyvale 3-22-10
or Imitation
One-to-One
Child-
Special
Education
Initiative
(Floor-Time/
SCERTS/RDI)
(TEACCH/
Other Special
Day Class)
General
Education
(Full or Partial
Inclusion)
Primary Likely Benefits
Yes
(via child
choice of
content
No
(completed
order as
reward)
No
(response
assumed)
No
(attention
directed to
stimulus
materials)
Yes
(major
focus)
No
(attention
directed to
routine or
materials)
Yes
(once imitation
present)
No
(object or teacher
models)
No
(adult as
model for
affiliation)
No
(inclusion w/
comparable
peers)
Yes
(IF peers are
interesting
models)
Yes
(via forward/
backward
chaining)
No
(adult as
model for
affiliation
Yes
(via paired
association)
Yes
No
(routine as
(IF salient peer
model)
models)
[email protected]
Area of
Autistic Learning
Disability
One-to-One
Adult-Led
One-to-One
Child-
(ABA-DTT/
PRT/ NET)
Initiative
(Floor-Time/
SCERTS/RDI)
COMMUNICATION
Poor
Comprehension/
Limited ParaLinguistics
Special
Education
(TEACCH/
Other
Special Day
Class)
General
Education
(Full or
Partial
Inclusion)
Primary Likely Benefits
Partial
(Rotely- taught/
non-generative)
Yes
(In context of
social
regulation)
Yes
(Routine as
Replacement)
No
(assumed at age
level)
Slow Auditory
Processing Speed,
Poor Parsing
Partial
(Telegraphic
Speech)
No
(May Assume
R > E)
No
(Emphasis on
visual)
No
(assumed at age
level)
Preference for
Visual over
Auditory Modalities
Yes
(Use of Visuals &
Procedures)
Yes
(Pairs words
with activity)
Yes
(Visually
sequenced
environment)
Multi-modal
earlier, then
auditory
No
(Reliance of Direct
Learning)
Yes
(Anticipation/
Prediction of
Other’s
Actions)
Theory of Mind/
Sunnyvale 3-22-10
Perspective-Taking
No
Yes
(work is
(via group
individual)
participation)
[email protected]
Area of
Autistic Learning
Disability
One-to-One
Adult-Led
(ABA-DTT/
PRT/ NET)
ORGANIZING
INFORMATION
Lack of
Representation
Capacity
(Imagination)
Preference for
Repetition over
Novelty
Sensory
Modulation
Difficulties
Sunnyvale 3-22-10
One-to-One
ChildInitiative
(Floor-Time/
SCERTS/RDI)
Special
Education
(TEACCH/
Other
Special Day
Class)
General
Education
(Full or
Partial
Inclusion)
Primary Likely Benefits
Partial
(Rotely- taught/
non-generative)
Yes (innovation
as main focus)
No
(more emphasis
on classification)
Partial
(if child imitates
& @ devel. level)
Yes
(adult-direction)
Yes (innovation
as main focus)
Yes
(time delimited
tasks)
Partial
(varied
curriculum if
child can follow
it)
Yes
(de-sensitization)
Yes
(gradual building
of reciprocity)
Yes
(controlled
physical
environment)
No
(environment
design for those
w/o difficulty)
[email protected]
In Conclusion
ABA is a powerful tool in the autism
treatment toolbox
 It’s not the only tool
 Integration of ABA methods with
developmental curriculum is the highest
standard for evidence-based treatment

[email protected]