Practical Interventions for Children with High Functioning Autism and Asperger’s Syndrome

1. Practical Interventions for Children with High Functioning Autism and Asperger’s Syndrome Lauren Kenworthy, Ph.D. and Laura Anthony, Ph.D.Wednesday, January 30th, 2008 CASD Outreach Night

2. Center for Autism Spectrum Disorders Faculty and Staff Lauren Kenworthy, Ph.D. Peter Daniolos, M.D Director Medical Director Pediatric Neuropsychologist Child and Adolescent Psychiatrist Laura Anthony, Ph.D. Kathleen Atmore, Psy.D. Clinical Child Psychologist Developmental Neuropsychologist Cheryl Anselmo, M.A., CCC-SLP Angela Bollich, Ph.D., SLP Speech and Language Pathologist Pediatric Neuropsychologist Joette James, Ph.D. Christine Amerasinghe/Katea Selby Pediatric Neuropsychologist Clinical Operations Representative Katie Jankowski/Jenni Sokoloff BenYerys, PhD/Rafael Oliveras, PsyD Research Assistant Post Doctoral Fellows

3. Autism does not have one cause or cure… The triad of impairments in autism can be fractionated and should be studied separately (Happe, Ronald & Plomin, 2006) • Single explanations of autism have not been successful at explaining social deficits and rigid/repetitive behavior • Autistic like behavioral traits in typical children (twin study 7-9 year olds) show only modest to low correlations (Ronald et al, 2006) • Autism is a heterogeneous disorder

4. Solution to the riddle: • Teach by doing • Teach process (make implicit explicit) • Go step by step • Provide hard copy

5. Teach by Doing: Harder Than You Think • Intervene in everyday activities with everyday people in the contextof a real problem • Explicitly decode reasons for change • Positive verbal labels

6. Teach by Doing: Harder Than You Think • Model behavior • Begin from an “external support” position, slowly encouraging internalization of routines • Teach until automatic

7. Teach by Doing: “With, Not For” • Collaborate with child • Give child opportunity to solve problem • Elaborate responses • Reward effort • Hold child responsible for outcome • Make all interventions positive

8. Goal-Plan-Do-Review • GOAL: WHAT DO I WANT TO ACCOMPLISH? • PLAN: HOW AM I GOING TO ACCOMPLISH MY GOAL? • MATERIALS/ EQUIPMENTSTEPS/ASSIGNMENTS • 1. 1. • 2. 2. • PREDICTION: HOW WELL WILL I DO? • Self rating 1 2 3 4 5 6 7 8 9 10 • Other Rating 1 2 3 4 5 6 7 8 9 10 • DO • PROBLEMSSOLUTIONS • 1. 1. • 2. 2. • 3. 3. • REVIEW: HOW DID I DO? • Self rating 1 2 3 4 5 6 7 8 9 10 • Other Rating 1 2 3 4 5 6 7 8 9 10 • WHAT WORKED?WHAT DIDN'T WORK • 1. 1. • 2. 2. • WHAT WILL I TRY NEXT TIME?

9. Incentives for Change • Motivation “Let’s work on your Harry Potter stuff” • Collaboration child and teacher or parent work together • Rewards individually identified based on each child’s interests, child will help develop the reward system • Positive Behavior Supports (PBS)including praise and concrete progress tracking (graphs, etc; Horner et al, 2002)

10. MUTUAL MISUNDERSTANDING “A failure to understand how a child’s typical behaviors reflect this disability can result in misperceptions such as viewing the child as noncompliant, willfully stubborn, or unmotivated, rather than confused, involved in repetitive routines, or focusing on less relevant aspects of the situation.” (Kunce & Mesibov, 1998)

11. Misunderstanding/Failure to Help • What exactly is the problem? • What is causing the problem? • Physical, Cognitive, Self Regulatory, Emotional, Behavioral • Vary conditions to test hypothesis • Team collaboration • On-going process

12. Placement Decisions • Minimum requirements • Staff with ASD expertise and team approach • Safe address • Specialized pull-out: social/executive support • Best Practice • Social/Executive support integrated • Small class size • Consider • Windows of Opportunity • Overload Effects

13. Overload • Structure, structure, structure • Preview transitions, post schedules, stick to routines • Limit the number of adults/peers who work with child • Give breaks from people • Avoid, decode or at least predict large group or unstructured events • Assign specific jobs or tasks

14. Misses “Big Picture” • Safe Address • Teach to strength: explicit short rules, recipes, checklists and routines • Predict decline in abilities as size/structure of group increases • Put new information in familiar context

15. Inflexibility • Use prediction, routine and repetition to support behavior • Make schedule clear and public • Forewarn of any changes in schedule • Give 2 minute warnings of time to change • Make changes from one task to the next, or one topic to the next, clear and explicit

16. Inflexibility • Assess understanding of situation, devise Social Story • Flexibility training • Script (“This is not part of the plan, is there a new plan?”)

17. LEARNet Problem-Solving System and Resource Website • Self-Regulation/Executive Function Issues • Problem Solving • Self-Monitoring and Self-Evaluating • Flexibility Versus Rigidity In Thinking and Behavior • Impulsiveness / Disinhibition • Inconsistency in Performance • Self-Regulation / Executive Function Routines After TBI • Transition Routines • Initiation • Cognitive Egocentrism / Theory of Mind

18. LEARNet Problem-Solving System and Resource Website • Advance Organizers • Attention • Organization • Retrieval and Retrieval Problems • Approaches to Teaching: Traditional Training vs. Apprenticeship • Word Retrieval and Word Retrieval Problems • Memory and Memory Problems • Slow Information Processing • Transfer of Training / Generalization • Reading Comprehension • Concrete vs. Abstract Thinking • Written Composition Authors: Mark Ylvisaker, Ph.D., Mary Hibbard, Ph.D., Timothy Feeney, Ph.D. The Brain Injury Association of New York State (2006)http://www.bianys.org/learnet

19. Poor Self-monitoring • Videos • Review situations with safe address • Metacognitive narrative • Slow interactions down • Build in explicit, routine checking procedures • Make predictions

20. Just Do What I Say! • Written rules, recipes, routines, checklists • Tapes • Hand held computers • Notebooks • Dry Erase boards • Talk out loud (Winsler, 2006) • Memorize it, make it automatic

21. Just Sit There! • Activity breaks • Increase structure in environment to set limits for inhibition problems • Make behavior and work expectations clear and explicit; review with student • Post rules in view; point to them when child breaks rule • Teach response delay techniques (counting to ten before acting) • Positive behavior management plans

22. Incentives for Change Intervention Project Collaboration with Ivymount Cognitive Instruction Improved flexibility in the classroom Primary outcome Better adaptive behavior Increased Flexibility Less missed instruction time Guided Practice Improved fluency and flexibility on cognitive tests Improved behavioral regulation and metacognition at school and home Generalization Training Improved social skills Improved flexibility at home

23. Early Intervention • Teach pretend play and joint attention skills (Kasari, Freeman and Paparella, 2006) • Imitate your child • Speech and Language therapy

24. Parent-child Interaction Therapy (Eyeberg, Herschell) • Child Directed Interaction • Positive play therapy • Developmental approach • Parent Directed Interaction • Compliance training • Behavioral approach

25. Applied Behavioral Analysis (Lovaas, 1987) • Intensive behavioral techniques (30-40 hours per week) • Targets basic language skills, behavior and academics • Research shows remarkable improvement in 50% of children • Most appropriate for early intervention in HFA, Asperger’s

26. ACTIVE Social Coaching Deconstruct social situations (e.g., Solomon, Goodlin-Jones, Anders, 2004) • Process social situations out loud • Name your own feelings, what other person might be thinking, feeling • Stop action while watching videos and ask: • Why did he do that? • What will she do next? • What is she feeling? • What will happen if _____? (Gena et al, 2005)

27. ACTIVE Social Coaching • Deconstruct social situations • Interpret facial expressions, gestures and body language out loud for your child • I can tell you are angry because_____ • I could tell she didn’t have time to talk because _______ • When I look at you this way, it means that _____

28. ACTIVE Social Coaching • Social mentors • Good for older kids and teens • Social activities around special interests • Pragmatic language therapy • Drama (Asperger, 1944) • Social Stories, Comic Book Conversations, social skills workbooks, etc • i.e., write it down! (Theimann and Goldstein, 2004)

29. Social Stories (Carol Gray) Riding the School Bus Valerie Lowing Some children ride to school on a bus. Usually the bus will pick me up in the morning and bring me to school. Some children like riding the bus. They think it is fun. Usually the bus will pick me up from school at the end of the day and bring me back home. Sometimes I will not ride the bus. Mom or dad will tell me when I will not ride the bus. http://www.thegraycenter.org/

30. ACTIVE Social Coaching • Social coaching in groups (e.g., RDI, McAfee) • Discrete skills • Eye contact, turn taking, listening • Pragmatic skills • Social scripts • “Opportunistic” skill building • Challenge tasks (Gutstein, 2000; McAfee, 2002)

31. Family Burden • Psychoeducation • Family navigators • “Similar to myself” support • Respite care • Encouraging movement towards advocacy and empowerment

32. Behavioral Intervention Strategies • Aversives • “No,” Time Out • Differential reinforcement • Replacement • Extinction • Stop reinforcing (IGNORE) • Antecedent (cause) manipulation

33. Behavioral Intervention for OCD and Phobias • Obsessive/compulsive or phobic symptoms can be treated by Exposure and Response Prevention Therapy • Create a fear hierarchy • Client picks where to start • Expose client to feared stimulus • Prevent escape/avoidance/compulsion • Wait for anxiety to reduce

34. Behavioral Intervention for OCD and Phobias • Must be done in the context of a trusting therapeutic relationship • Must be led by the child, and under child’s control • May take longer for those with ASD

35. Anxiety • Relaxation training • Guided imagery • Special interests • Meditation • Adapted yoga • Cognitive Behavioral Therapy to help identify anxiety, accept it without being overwhelmed, and use cognitive strategies to reduce anxiety

36. Compliance • Reward when intrinsic motivation doesn’t work • Collaborate together on behavior plan • Integrate behavior plan in home and at school • Rewards and praise work better than loss of privileges or punishments • Magic ratio of 1:5

37. Attention Problems • Environmental adaptations • Deep pressure • Attention training sessions (using behavioral methods) • Joint attention training in young children

38. Meltdowns • Prevention (warnings, preparation, practice) • Wait for the storm to pass • Do not “give in” once meltdown has started • Don’t talk • Provide safety and reassurance • It is not your fault, don’t take it personally

39. Preparing Now for Adulthood • Almost no research on long term outcomes • All information is on current adults using retrospective data • Adults with AS seem to continue to make progress in core symptoms • Best indicator of prognosis may be peer relationships

40. Asperger’s in Adulthood • Transition planning and training must start in middle school (elementary school if you consider daily living skills) • Work issues: interests vs. skills • College • Need for support • On-line vs. mainstream

41. Foundational Skills • Personal hygiene and professional dress • Time management skills • Professional demeanor (eye contact, handshaking skills, etiquette) • Limit lectures and talk of special interest • Increasing tolerance for boring tasks • Taking instruction

42. Summary • Interventions need to be multi-disciplinary • ASDs are developmental disorders, so expect changes in skills and problems • Swiss cheese syndrome

43. Resources • Autism Asperger’s: Solving the Relationship Puzzle by Steven Gutstein, PhD (Future Horizons) • Navigating the Social World by Jeanette McAfee, MD (Future Horizons) • Executive Skills in Children and Adolescents, Dawson and Guare (Guilford Press) • Cartoon Cut-Ups Teaching Figurative Language and Humor, Jean Hamersky (Thinking Publications)

44. Resources • College Internship Programs-Examples • The Brevard Center, Melbourne, FL, 1-866-603-1900 • The Berskhire Center, Lee, Massachusetts (413) 243-2576 http://www.berkshirecenter.org • Foothill College Transition to Work Program Los Altos Hills, CA, (650) 949-7242http://www.foothill.edu/al/ttw.html

45. Resources • Meyer, R.G. (2001). Asperger Syndrome Workbook: An Employment Workbook for Adults with Asperger Syndrome. London & Philadelphia: Jessica Kingsley Publishers. • Smith, M.D., Becher, R.G. & Juhrs, P.D. (1995). A Guide to Successful Employment for Individuals with Autism. Baltimore: Paul H. Brookes Publishing Company.

46. Resources • Autism Society of America www.autism-society.org • Yale info.med.yale.edu/chldstdy/autism/welcome.html • TEACCH www.unc.edu/depts/teacch • National Information Center for Children and Youth with Disabilities www.nichcy.org

47. Resources • Future Horizons www.FutureHorizons-autism.com • National Academy Press (free version of Educating Children with Autism, 2001) www.nap.edu • OASIS http://aspergersyndrome.org/

48. Resources • Autism Speaks www.autismspeaks.org • Organization for Autism Research http://www.researchautism.org/ • www.NationalAutismAssociation.org Direct grants to families • www.take2camp.org • www.dcchildrens.com (Click on Departments and Programs)