Transcript Slide 1

The CARD
Treatment Program
Doreen Granpeesheh, Ph.D.
GPL Conference
Anaheim, California
Center for Autism and Related Disorders, Inc
Today’s Discussion
What is ABA?
The CARD Treatment Model
The CARD Curriculum
Case Study and Data
What is ABA
ABA is based on principles of Operant
Conditioning Theory
Operant Conditioning Theory:
Human Behavior is affected by events that
precede it (antecedents) and events that
follow it (consequences)
Application of ABA to the
Treatment of Autism
Symptoms Classified as:
Deficits


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

Language
Play
Social Skills
Theory of Mind
Executive Functions
Skill Repertoire Building
Excesses
 Self Stimulatory Behs
 Maladaptive Behs
• Tantrums
• Aggression
• Noncompliance
Behavior Management
The CARD Treatment Model
ABA Foundation
Serve children from 18
mo – 8 yrs
Intensive treatment
Bi-Weekly supervision
Shift from home-based
1:1 learning to peer &
community based
learning opportunities
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
The CARD Treatment Model:
Beginning Level
Services:
30-40 hours of 1:1 in-home
behavioral intervention
Targets:
Build a relationship with the child
Increase child’s initiation with us
Increase Compliance
Language Training - Requests
(Mand Training)
Language Training - Receptive &
expressive object & action labeling
(Tact Training)
Imitation, toy play, & pretend play
Self-help skills
The CARD Treatment Model:
Intermediate Level
Services
20-30 hours of 1:1 in-home intervention
5-10 hours of preschool with a CARD shadow targeting
social skills & generalization
Skills Taught
Asking Wh Questions
Conversational language
Generalize language to play
& peer situations
Emotion recognition
Sociodramatic & imaginary
play
Basic cause and effect
Emphasis on generalization
& playdates begin
The CARD Treatment Model:
Intermediate Advanced Level
Services
20 hours of therapy per week:
 Includes 1:1 & playdates in home & in the community
20 hours school with shadow
Skills Taught
Classroom routines
Following complex & group
instructions
Making inferences
Observational learning
Social skills and peer
interaction
Pragmatic Language (e.g.,
introducing a topic,
maintaining a conversation)
Self-monitoring, Planning and
Problem Solving
The CARD Treatment Model
Advanced Level
Services
5 - 10 hours per week at home (fading out)
Gradual fading of school shadow
Skills Taught
Social perspective taking
Academics
Continued selfmonitoring
Advanced pragmatics
(e.g., detecting sarcasm)
Completion of parent and
teacher training
The
CARD
Curriculum
The CARD Curriculum
School
Skills
Self Help
Executive
&
Function
Motor Skills
Language
Play
Theory
of
Mind
Social
Skills
The CARD Curriculum:
Some general points
The child’s individual
learning style is
considered before
particular skills are
introduced
Visual Modification
suggestions in each
program, for visual
learners
Verbal Behavior
framework used in all
language programs
Generalization
 Emphasized from very
early on
 At least 5
generalization ideas for
each skill taught
 Flexibility worksheets
for each Language
program to ensure
generalization
The CARD Curriculum
School
Skills
Self Help
Executive
&
Function
Motor Skills
Language
Play
Theory
of
Mind
Social
Skills
The CARD Curriculum
Language
Sample Program: Colors
Function
Imitation
Antecedent
Mom says, “blue”
Requesting Jody is ready to finger
Child’s Behavior
Jody says, “blue”
Jody says, “blue paint”
(Mand)
paint, but no paint
Matching
3 color cards on table
Jody matches blue cards
Receptive
3 crayons present & mom
says, “give me blue”
Jody hands mom the blue
crayon
Labeling
Jody sees a blue car
Jody says, “blue”
(Tact)
Conversatn Mom asks, “What color is
(Intraverbal) the sky?”
Jody says, “blue”
The CARD Curriculum
Language
Overall Goals in Teaching Language
Emphasis on ensuring spontaneity in
language use
Emphasis on teaching language that is
functional in everyday situations
Emphasis on generalization
The CARD Curriculum
School
Skills
Self Help
Executive
&
Function
Motor Skills
Language
Play
Theory
of
Mind
Social
Skills
The CARD Curriculum Play
Target Areas
Games with
Rules
Independent
Play Tracking
Beginning
Play
Functional
Pretend Play
Practice
Play
Sociodramatic
Play
Imaginary
Play
Symbolic
Play
Constructive
Play
The CARD Curriculum Play
Features of a Comprehensive Play Skills Program
 Modeled
after the development of play skills in
typically developing children
Breaks down each type of play into its own
systematic and comprehensive program
Sequential format
Programs may be used individually, concurrently,
or cumulatively
The CARD Curriculum Play
Typical Development of
Play Skills
The child observes &
explores
Progression of play targets
within CARD program
Our client imitates therapist/
parent in a 1:1 setting
The child rehearses the skill Reinforce independent
on their own
practice of play skill & track
Independent Play to ensure
spontaneity
The child generalizes the
Target mastered solitary
skill to social situations
play in Social Play program,
to generalize with peers
The CARD Curriculum Play
Sample: Functional Pretend Play
Pretend Imitation with Functional Objects
Pretend Receptive Commands with Functional
Objects
Vocalization of Pretend Play with Functional
Objects
Expressive Identification / Narration
Creation and Initiation of Pretend Play with
Functional Objects
Requesting Pretend Play with Functional Objects
The CARD Curriculum
School
Skills
Self Help
Executive
&
Function
Motor Skills
Language
Play
Theory
of
Mind
Social
Skills
The CARD Curriculum
Theory
Of
Mind
Theory of mind or Social Cognition is concerned
with how children learn to conceptualize other
people, growing an understanding of others’
Viewpoints
Thoughts
Emotions
Intentions
The CARD Curriculum
Theory
Of
Mind
Social Cognitive Impairment in Autism
Inability to infer or empathize others’ desires / feelings
Inability to consider what others know
Inability to consider what others are thinking
Inability to infer others’ beliefs / opinions
Inability to consider unintentional behavior
Inability to infer communicative intent
Inability to understand or engage in deception
Inability to coordinate multiple social cues in a given
social scenario
The CARD Curriculum
Theory
of
Mind
9 Target Areas
Emotions
Deception
Desires
Intentions
Sensory
Perspectives
Beliefs
Knowing
Thinking
Preferences
The CARD Curriculum
Sample Program: Knowing
Theory
Of
Mind
The child learns that people know things based on the
following tenets:
Knowing from Seeing
Knowing from Hearing
Knowing from Smelling
Knowing from Feeling
Knowing from Tasting
Multi sensory Knowing
Knowing from remembering
Knowing from asking
Self Knowledge (First Person)
Others’ Knowledge (Third Person)
Knowing Program: Sd’s 4-6
Sd 4a: “Do I know what (label/attribute/feature/etc?”)
R 4a: “Yes/No”
Sd 4b: “Why?”/ “How do I know?”/ “Why Not?”
R 4b: “Because you can/can’t see/hear/smell/feel/taste it”/”
Sd 5a: “Does 3rd person know what (label/attribute/feature/etc?”)
R 5a: “Yes/No”
Sd 5b: “Why?”/ “How does he/she know?”/ “Why Not?”
R 5b: “Because 3rd person can/can’t see/hear/smell/feel/taste it”/”
Sd 6a: “Who Knows what (label/attribute/feature/etc?)”
R 6a: Child identifies appropriate person
Sd 6b: “How does person know?”
R 6b: “Because person can see/hear/smell/feel/taste it”/”
The CARD Curriculum
School
Skills
Self Help
Executive
&
Function
Motor Skills
Language
Play
Theory
of
Mind
Social
Skills
The CARD Curriculum
Social
Skills
What skills are taught?
 Choral Activities
 Community Social
Behavior
 Social Play
 Following Rules
 Sharing
 Tattling
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Group Discussions
Levels of Friendship
Self Esteem
Apologizing
Cooperative Work
Dealing with Conflict
Safety Awareness
Winning and Losing
The CARD Curriculum
Sample Program
Social
Skills
Levels of Friendship
 Child learns to identify
the degree of
relationship he
experiences with people
in his environment
 Child learns to identify
and rehearse behaviors
that are appropriate to
each relationship
Best Friends
Friends
Acquaintances
Strangers
The CARD Curriculum
School
Skills
Self Help
Executive
&
Function
Motor Skills
Language
Play
Theory
of
Mind
Social
Skills
The CARD Curriculum
Components

Self-Help
• Eating & drinking
• Toileting
• Dressing
• Bathing
• Household Chores

Self Help
&
Motor Skills
Fine Motor Skills
• Arm/hand/finger strength
• Drawing
• Cutting
• Coloring
• Writing
 Gross motor skills
•
•
•
Walking & running
Ball skills
Riding a bike
The CARD Curriculum
School
Skills
Self Help
Executive
&
Function
Motor Skills
Language
Play
Theory
of
Mind
Social
Skills
The CARD Curriculum
What is Executive Function?

Processes that
underlie goal
directed behavior
Executive
Function
The CARD Curriculum
Executive
Function
Goal Directed Behavior Involves…
Visualizing situation
Identifying desired
objective
Determining plan to
meet objective
Monitoring progress
to goal
The CARD Curriculum
Executive
Function
Inhibition
Planning &
Problem Solving
Flexibility
SelfMonitoring
Working Memory
Attention
The CARD Curriculum
School
Skills
Executive Self Help
&
Function
Motor Skills
Language
Play
Theory
of
Mind
Social
Skills
The CARD Curriculum
School
Skills
Scope
Math

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
Addition & Subtraction
Advanced Counting
Money
Telling Time
Reading
Comprehension
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

Book Topography
Story Comprehension
Story Summarizing
Text Comprehension
Spelling
 Copying and Dictation
 Rhyming
Vocabulary
 Synonyms and Antonyms
 Thematic Vocabulary
Joey’s Story:
A Case Study
A case study: Joey
Joey was diagnosed with Autistic Disorder in
December of 1995.
CARD Treatment was initiated in February of
1996 at the age of 3 years, 6 months.
Treatment intensity ranged from 30 to 40 hours
per week of 1:1 in-home and school based
behavioral intervention for approximately 2 ½
years
Joey’s Repertoire at Intake:
Deficits:
Excesses:
Profound Delays
Frequent Nonin Joint
compliance
Attention
Frequent Tantrum
Minimal
Behavior
Language
Self-Stimulatory
Inability to
Behaviors: Lining
Interact Socially
with Peers
objects, “video
talk”, obsessions
No Purposeful
Concrete or
with trains, hand
Imaginative
flapping and
Play
gazing
Echolalia
Skills:
 One word
expressive labels
 Simple imitation
 One step receptive
instructions
 Some single word
responses to social
questions
At Intake…
Services: Year One
 Full inclusion in general education pre-school
(12 hours p/w).
 Full-time CARD shadow in the classroom.
 25 hours per week home based behavioral
intervention.
Intervention: Year One
Acquiring stimulus
control of pre-existing
behaviors
Increasing compliance to
requests
Mands
Increasing attending
behavior
Reducing maladaptive
behaviors
Object labels (including
names, animals, places)
Actions / verbs
Attributes (including
colors)
Play Skills
Identifying emotions
Following instructions
(increasing complexity)
Functions
Gender
Categories
Academic skills (Letters
and Numbers)
Plurals, tenses, pronouns
At 3 Months…
At 4 Months…
At 5 months…
At 6 Months…
Number of taught
Programs
Year-One Progress Chart:
Mastered Programs
50
40
30
20
10
0
1
4
7
10 13 16 19 22 25 28 31
Month
Number of Subskills mastered
Year-One Progress Chart:
Mastered Sub-skills
160
140
120
100
80
60
40
20
0
1
4
7
10
13
16
Month
19
22
25
28
31
Number of taught
Operants
Year-One Progress Chart:
Mastered Responses
1800
1600
1400
1200
1000
800
600
400
200
0
1
4
7
10 13 16 19 22 25 28 31
Month
Services: Year Two
 Full inclusion in general education preschool 20
hours per week.
 Full-time CARD shadow in the classroom
 25 hours per week of home based intervention
Intervention: Year Two
Intermediate Social
Program
 Getting attention of
listener before
talking
 Initiating play and
Joining a group
 Regulating volume
of speech
 Reading the body
language of others
 Sharing
 Turn taking
Responding to Emotions
Conversational skills
Pragmatic language
skills
– Adjusting conversation
according to audience
(perspective taking)
– Introducing a topic
– Staying on topic
– Providing sufficient
information to listener
– Ending / closing conversation
At 12 Months…
At 15 Months…
Number of taught
Programs
Year-Two Progress Chart:
Mastered Programs
50
40
30
20
10
0
1
4
7
10 13 16 19 22 25 28 31
Month
Number of Subskills mastered
Year-Two Progress Chart:
Mastered Sub-skills
160
140
120
100
80
60
40
20
0
1
4
7
10
13
16
Month
19
22
25
28
31
Number of taught
Operants
Year-Two Progress Chart:
Mastered Responses
1800
1600
1400
1200
1000
800
600
400
200
0
1
4
7
10 13 16 19 22 25 28 31
Month
Services: Year Three
 Full inclusion in general education kindergarten
 Fading of full time “unknown” CARD shadow
 10 hours per week of home based intervention
Remaining Deficits and
Excesses
 Insufficient or irrelevant descriptions and explanations
 Inappropriate use of questions, initiations, topic
selection and conversations
 Inappropriate body language
 Avoidance of new people and places
 Inflexible, routine based play
 Frequent crying during social activities
 Difficulty entering a game in progress
 Inappropriate reactions to joking and playful teasing
 Deficient friendship development and friendship
maintenance behaviors
Intervention: Year Three
 Identifying simple
intentions
 Social cause and effect
 Knowing
 Think, feel, say, do
 Joking, teasing, lies and
deception
 Topic selection
 Topic introduction
Topic maintenance
Asking questions
Making statements
Play
Social outings
At 27 Months…
Number of taught
Programs
Year-Three Progress Chart:
Mastered Programs
50
40
30
20
10
0
1
4
7
10 13 16 19 22 25 28 31
Month
Number of Subskills mastered
Year-Three Progress Chart:
Mastered Sub-skills
160
140
120
100
80
60
40
20
0
1
4
7
10
13
16
Month
19
22
25
28
31
Year-Three Progress Chart:
Mastered Responses
Number of taught
Operants
2000
1500
1000
500
0
1
4
7
10 13 16 19 22 25 28 31
Month
Treatment Gains
Age Equivalent
Vineland Adaptive Behavior Scale
10.0
8.0
6.0
4.0
2.0
0.0
Age 3.6 Age 4.1 Age 5.5 Age 7.7 Age 8.6
Behavior
Communication
Daily Living
Socialization
Treatment Gains
Wechsler Intelligence Quotients
120
100
80
PSIQ
VSIQ
FSIQ
IQ 60
40
20
0
7 mths Tx
2 yrs Tx
1 yr Post-Tx
At Discharge…
In January of 1999, Joey no longer presented with
any of the behavioral excesses or deficits observed
at intake and services were terminated.
Joey’s original diagnosis was removed by an
independent clinician from an outside agency.
Currently, Joey is fully mainstreamed and
thriving academically and socially in a regular
education second-grade placement.
As reflected in the assessments, Joey not only made
significant gains in all areas of adaptive and
intellectual functioning, but continued to progress
even 2 years post-treatment.
C.A.R.D.’s
Preliminary
Outcome Data
CARD Outcome Study
Purpose
 Examine the effectiveness of early
intensive ABA
 Explore impact that intensity of 1st year of
treatment has on outcome
CARD Outcome Study
Overall Participant Information
 79 children participated
•
•
63 boys
16 girls
 Average age at intake: 39.1 months
 Average IQ at intake: 76.8 (mild mental
retardation)
 Length of time in tx: At least 3 years
 (Children initiating program from 3/92-6/96)
CARD Outcome Study
Participant Information:
High & Low 1st Yr. Intensity Groups
 Of the 79 children participating:
• 35 low intensity
• 44 high intensity
 The 2 groups were equivalent at intake in all
areas examined
• Age
• IQ
• Language
• Maladaptive Behavior
• Adaptive Behavior
CARD Outcome Study
Intervention:
 Hi Intensity Group: Received 26 or more
hours of CARD services (including school
aide) per week.
 Low Intensity Group: Received 25 or fewer
hours of CARD services (including school
aide) per week.
CARD Outcome Study
Mean Client IQ Pre- and Post-Treatment
100
High Intensity
IQ Standard Score
95
90
85
61%
80
75
70
Low Intensity
20%
1
Pre-Treatment
2
Post Treatment
CARD Outcome Study
Mean Adaptive Functioning Pre- and
Post-Treatment
Vineland Standard Score
100
95
High Intensity
90
85
61%
80
75
70
65
60
Low Intensity
20%
1
Pre-Treatment
2
Post Treatment
CARD Outcome Study
Normal IQ, Adaptive Fxn
and Placement
70
60
Percent
50
61%
40
30
20
10
0
20%
25 hrs or 1less / wk
2
26+ hours
/ wk
CARD Outcome Study
Factors Associated with Positive
Outcome
Intensity: 26+ Hours per
week Intervention
Age at Intake:
Treatment initiated prior
to age 4
Parent Participation:
Parents conduct therapy,
attend clinics, read log
book
Exposure to Typical
Peers: When school is
introduced, Regular
Education is best
Concurrent Medical
Management of
Symptoms: Dietary
changes & use of meds
Verbal Imitation within
the first 6 months of
treatment
Questions
CARD
GPL
Dr. Doreen
Granpeesheh Conference
Visual Modifications
Designed based on the child
Some examples
 Picture Exchange Communication System
(PECS) for children with difficulty
communicating vocally
 Stimulus modifications for children with
difficulty with auditory comprehension
 Response modifications for children with
difficulty with vocal output