Transcript Combining Treatment Approaches in Working with Children

By
Tracy Vail,MS,CCC/SLP
Letstalksls.com
What Are Important Skills to Teach Young Children
with Autism?
 Communication skills: allow the child to get their
needs met and replace maladaptive behaviors and
engage in social interactions.
 Non-verbal communication: Teaches the child that
people’s faces/bodies carry important information.
 Interactive Play Skills: teaches flexibility, improves
relationships, replaces self-stimulatory behaviors
 Imitation Skills: Allows the child to learn from the
environment.
Ask and Observe
 Ask the parents! What are their priorities?
 Observe the child- What areas are causing the child
the most difficulty in life right now?
 Look at where the child is currently functioning and
determine the necessary component behaviors/skills
to meet the goals of the parents and child.
 What are the goals of the family in 1 yr? 5 yrs? 10
yrs?
Most Common Approaches Used
 Behavioral Approaches- ABA- Applied Behavior
Analysis and Applied Verbal Behavior, TEACCH
 Developmental Approaches- SCERTS,
Floortime/DIR, RDI
Developmental, Individual Differences,
Relationship Based Intervention,
DIR/Floortime
 A warm and intimate way of relating to a child.
A floor time philosophy means engaging,
respecting and getting in tune with the child in
order to help the child elaborate through
gestures, words and pretend play what is on the
child’s mind. As a technique it is a process that
is used to support the emotional and social
development of the child. (Greenspan, 2002)
This model serves as the context or “container” of the therapy we do.
But what does it mean?
Relationship Development
Intervention (RDI)
 A cognitive- developmental approach designed
to remediate Autism.
 Deals with autism as a neurologically based,
information processing disorder.
 Proposes to remediate the “Core Deficits” in
Autism including motivation, communication,
emotional regulation, episodic memory, rapid
attention shifting, self-awareness, appraisal,
executive functioning, flexible thinking, and
creative problem solving.
Great stuff based on research by many in the field of psychology but what
do these “core deficits” mean? How do we know when these skills have
improved? What is the child doing? How can we measure it? AND, is it
really necessary to spend thousands of dollars being trained to address
these issues?
Hanen Method
 Teaching communication and play skills through
adult- child interactions. Parents/therapists are to:
 Observe, Wait and Listen (OWL)
 This approach is very similar to DIR in that the child
leads and teaching is conducted based on the
interests of the child.
Behavioral Approaches
 Scientifically validated based on many years of
research.
 Based on measurable behaviors either internal or
observable.
 Based on the “laws of learning”
 Places the responsibility of learning on the
“teacher” rather than the student
 Many “faces” to behavioral interventions. Not
all programs look alike
 Data driven program decisions
Applied Verbal Behavior
 Based on the research of BF Skinner on “why”
people communicate
 Language is categorized into verbal operants or
functions: Mand, Tact, Echoic, Intraverbal (as
well as “listener” behaviors)
 There’s a strong focus on developing
“intraverbal links” or relationships between
words.
 Language is taught as a behavior with specific
teaching procedures used
 Both natural environment teaching and intensive
teaching are used based on the age and skills of
the child
TEACCH
 The long-term goals of the TEACCH approach are both skill
development and fulfillment of fundamental human needs such as
dignity, engagement in productive and personally meaningful
activities, and feelings of security, self-efficacy, and selfconfidence. To accomplish these goals, TEACCH developed the
intervention approach called “Structured Teaching.”
 The principles of Structured Teaching include:
 Understanding the culture of autism.
 Developing an individualized person- and family-centered plan
for each client or student, rather than using a standard
curriculum.
 Structuring the physical environment.
 Using visual supports to make the sequence of daily activities
predictable and understandable .
 Using visual supports to make individual tasks understandable
(TEACCH Website)
Can We Combine Behavioral and
Developmental Approaches?
YES!!!
Factors to Consider
 No single “program” works for all children to
address all their needs.
 Every human being’s learning is a combination of
internal and external factors.
 Motivation of the child is the most important factor
to consider when making treatment decisions.
 Parents often have preferences and skill sets that
should be respected.
 Different children respond better to different
approaches.
Relevant Information About Learners
with Autism
 They tend to have very analytical minds
 They tend to have unusual motivations and
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consequently unusual reinforcers
They tend to be “rule based” learners
Their bodies experience the world in an unusual way
Some are quite rigid and anxious
They often have difficulty understanding the “rules”
of social interaction and communication
So what…..Now what?
Use Whatever Works to
Teach the Most Important
Skills to each Individual
child at the Given Time
The Language We Use
 Often it isn’t what we do but how we talk about
what we do that makes approaches seem so
different.
 The language we use to talk about what we do
should be precise, agreed upon and based on
“observable” or “measurable” change.
 As professionals we are charged to provide
“evidenced based practices”. Show me the data!!
What do you see
happening?
A Few Possible Observations
 He interacted with the
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instructor for 3.5 minutes.
He requested using gestures 4
times with no prompting.
He imitated body movements
twice with no prompting.
He looked at the instructor
twice and smiled.
He laughed in response to the
instructors actions twice.
He initiated a social game twice
with no prompting.
 He shared affect
 He shared attention
 He both opened and closed 5
circles of communication
 The instructor followed the
child’s lead
 He demonstrated a preference
to engage in a regulatory
pattern with ongoing variations
 He regulated his actions to
maintain social coordination
 He responded to guides role
actions to maintain the
regulatory status of the pair.
Children are Complete Human
Beings
 They have a right to communicate to get their
needs met
 They want and need successful relationships in
their lives
 While they have some similarities, they all have
unique needs that should be addressed
 Each family structure is different and has unique
priorities and needs
 Child and family needs will change over time
and programs need to reflect that
General Language Categories
 Language used to meet the needs of the individual
 Language used for social interactions and building
relationships
 Language used for “learning” or academic settings
Verbal Operants
Antecedent/Stimulus
Mand
Motivation
Behavior
Says “car”
Consequence
gets car
Echoic
“Say car”
Says “car” social/secondary
Tact
Car present
Says “car” social/secondary
Intraverbal “We ride in the ..”Says “car” social/sec.
Motivation and
Reinforcement
Motivation1. Temporarily increases the value of a reinforcer
2. Temporarily increases the behaviors that have been
followed by that reinforcer in the past
Reinforcer- increases the likelihood that a behavior
will happen again in the future
If a behavior is increasing in frequency, it is being
reinforced!
Communication To Meet Needs
 Mands/requests
 Use an augmentative system if the child is not yet
vocal: signs, PECS, voice output devices
 Teach “errorlessly”- full prompts then fade your
prompts
 Make sure you have motivation before teaching the
request
 Target 3-4 words at any given time.
Conditions to Teach
 Fill-ins: choo choo little …R= train
 Echoic- shape articulation
 Choices- Block? Car? – Do you want block
or car?
 What do you want? What should I do?
 Noting said- object present
 Nothing said- object absent (pure mand)
Choose a Response Form
 If child is non-vocal, must use an
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alternative/augmentative system
Augmentative communication encourages rather than
discourages vocal productions
Experiment to determine how the child responds to
various forms
Picture/object exchange
Signs
Communication Boards
Vocal
Voice output devices
Teaching Signs
 Make sure the signs you teach can be immediately
reinforced.
 Choose iconic signs to begin teaching (look like the
object)
 Make sure all those in the child’s environment know
the child’s signs so they can be reinforced.
 Early signs to avoid: more, yes/no, potty, open
 Think: Objects, then actions, then adjectives
Introducing Signs
Signing Block
Picture Exchange Communication System
Communication Boards
Shaping Speech
 Begin with vowels since they carry the most
meaning
 Shape the syllable structure to increase intelligibility
 Avoid teaching simplification patterns typical in
young children as they tend to be VERY hard to
correct in children with Autism.
 Continue reinforcing requests with augmentative
systems until vocals are intelligible to most people
 Always say the word correctly before delivering the
reinforcer
Avoid Dropping Sounds too Early
Watch for Sign/Vocal Confusion
Reinforce All Vocal Attempts
Use Imitation
Shape Speech in the Context of
Requesting
Use Music
Use Books
Avoid reinforcing extra sounds
Interactive Play
 Build trust/relationship by being
predictable
 Teach flexibility by slowly introducing
change
 Focus on engagement, shared affect, joint
attention
 Social imitation, social smiles
 non-verbal communication
Move In and Out of the
Comfort Zone
Comfort
Zone
Learning
Zone
Over the
Edge
Beginning Patterns
 Start a pattern based on what the child is doing or
introduce your own pattern
 Make sure the child has a role in the interaction.
You can be doing the same things or different things.
 As soon as the child is taking a role consistently,
vary the pattern. If the child withdrawals from the
interaction, make the change more gradual next
time.
 Use silly sounds, breath intake, pauses right before
the change will occur.
 Reinforce behaviors you want to see more of!
Follow the Child’s Lead
Facial gazing, social imitation,
pattern
Use the child’s interests
Expand Language and Play Skills
Advanced Pretend Play
Negotiating/Problem Solving
Non-Verbal Communication
 Pairing Experience – pairing people with
reinforcement/establish social
reciprocity/engagement- non-verbal behaviors
exhibited by 2 people for the function of sharing
reinforcing interactions. (many may be considered
requests for the interaction to continue- imitate as a
mand for the “listener” to repeat the behavior.)
Affect Sharing/Social Smiles
Imitation/Shared Affect
 Mirroring Behaviors:
 Shared affect- Reinforced by adult
imitating the child’s affect in an
exaggerated manner.
 Social imitation- reinforced by continued
presence of adult/child who’s attention
has been established as a conditioned
reinforcer.
Use Sounds and Pauses to Increase Facial
Gazing and Shared Affect
Non-vocal Requests
Mands/Requests= non-vocal behaviors exhibited by the
child that serve the function of obtain an item or action
 Look- reinforced by obtaining access to the item being
looked at.
 Reach (+ look)- reinforced by obtaining access to the item
being reached for.
 Point (+look)- reinforced by obtaining access to the item
at which the child pointed
 Give to activate (+look)- reinforced by activation of the
object/toy.
 Action to sustain (+look)- reinforced by repetition of the
action.
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Following Non-Verbal Directions
 Gestural Listener= responding to gestural
mands/requests of others to exhibit a behavior.
 Follow point – reinforced by adult attention or other
conditioned reinforcer
 Follow gaze- reinforced by adult attention or other
conditioned reinforcer
 Follow yes/no- reinforced by adult attention or
other conditioned reinforce.
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Following Point
Chains of Behaviors
 Combined- chains of behaviors that involve looking
to request information then following a non-verbal
receptive instruction.
 Look + follow point- look is reinforced by having
information provided and follow point is reinforced
by conditioned reinforcement
 Look + follow gaze- look is reinforced by having
information provided and follow gaze is reinforced
by conditioned reinforcement
Moving from Point to Gaze
Combined Continued
 Look + respond to head nod/shake (yes/no)- look is
reinforced by obtaining information and response to
yes/no reinforced by conditioned reinforcement
 Point and look + respond to head nod/shake
(yes/no)- point and look reinforced by obtaining
information and response to yes/no reinforced by
conditioned reinforcement
Joint Attention
 Gestural Bid for Joint Attention = child exhibits
non-verbal behaviors for the function of drawing
another’s attention to an object, event, or other
environmental stimulus. The attention of the adult
must be established as a conditioned reinforcer.
(True Joint Attention as defined in behavioral
literature)
 Show object (+look)- reinforced by affective
response/attention of adult/child
Joint Attention Cont.
 Look at object (+ look at person) reinforced by
affective response/attention of adult/child
 Give object (+look)- reinforced by affective
response/attention of adult/child
 Point at object (+ look)- reinforced by affective
response/attention of adult/child
Thanks for All You Give to Children!