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Maximizing Outcomes for Young Children with Autism Spectrum Disorders: Defining Intensity of Intervention. Phil Strain & Ted Bovey Positive Early Learning Experiences Center. Opening Discussion.
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Maximizing Outcomes for Young Children with Autism Spectrum Disorders: Defining Intensity of Intervention Phil Strain & Ted Bovey Positive Early Learning Experiences Center
Opening Discussion What are the key program features currently in place that you relate to positive outcomes for children?
General Principals • All interventions require a minimum amount of time to be effective. • A sole focus on hours as a measure of intensity is misguided. • Yet Doctors, interventionists, other providers AND parents continue to make treatment recommendations or requests based on hours. • Where do recommendations for x number of hours come from? • Lovaas (1987) study. • National Research Council (2001) book Educating Children with Autism.
Getting to Quality Outcomes is Not Just About Hours of Direct Services • We suggest, getting to quality outcomes is a complex process that involves many components including: • Social validity (functionality) of goals • High numbers of meaningful response opportunities • Comprehensiveness of intervention • Fidelity of intervention delivered • Utilization of data-based decision-making
The Formula for Success Social validity of goals x Response opportunities x Comprehensiveness of intervention x Fidelity of intervention delivered x Data-based decision-making = Quality Outcomes
Social Validity of Goals • Why is this so important? • Not enough time to teach everything or something trivial. • Addresses Functional Outcomes • Helps ensure consumer satisfaction. • Think beyond child outcomes (e.g., parent’s skill acquisition, their ability to address everyday activities, general reduction in parental stress)
What Makes an Outcome Functional? Links directly to communicating wants, needs and aversions. Links directly to child participation in typical activities and routines. Links directly to gaining access to typical peers. Links directly to improving independent movement, participation & communication. Links directly to preparation for success in future environments (criterion settings). Links directly to parent’s availability and skill(s) related to everyday routines.
Activity – Functional Outcomes Given the following scenario please discuss and come up with one outcome with High Social Validity. A family is struggling with their bedtime routine(s), including oppositional behavior, parental frustration, lack of sleep and potential safety issues. A family has a child with low cognitive skills, is nonverbal and does not follow simple directions. This skill deficit is particularly upsetting during meal preparation when Mom is not readily available.
Creating Multiple Meaningful Learning Opportunities • Why is this so important? • If other variables are held constant (learning opportunities are meaningful, focused on functional skills, delivered with fidelity, and reinforced) then more opportunities will result in more rapid skill acquisition. • Lots of practice needed to reach Fluency and Independent Performance.
Creating Multiple Meaningful Learning Opportunities • Easy with traditional adult directed instructional strategies (DTT). • How do you do it effectively using Naturalistic Teaching methods? • Isolate teaching objectives (what am I working on now). • Increase likelihood of teachable moments through use of everyday activities, preferred materials and child choice.
Video Video courtesy of Center on the Social and Emotional Foundations for Early Learning.
Video Video courtesy of UCSD Autism Intervention Research Laboratory
Activity – Creating Learning Opportunities • Given the outcomes below, identify multiple opportunities to target this skill throughout a variety of daily activities and routines. • Comes to parent when name is called. • Identifies body parts. • Asks for a desired item. • Dresses and undresses self. • Part II
Comprehensiveness of Intervention • Why is this so important? • No evidence of spill-over effects from one intervention focus to another. • Children with ASD have many needs directly related to autism symptomology! • Language & Communication • Social Skills and Social Reciprocity • Stereotypic Behaviors
Comprehensiveness of Intervention • Children with ASD often also have many needs NOT directly related to autism symptomology! • Functional Playskills • Persistent challenging behaviors (e.g., tantrums, aggression) • Motor skill delays • Self Help Skills (eating, sleep and toilet training).
Comprehensiveness • Key is that intervention goals must be individualized based upon the child and families needs. • Errors occur in two ways: • Over-programming & Under-programming • Leads to the Conundrum of Autism Curricula.
Fidelity of Intervention • Why is it so important? • High correlation between fidelity and outcomes • Little if any evidence that children with autism learn from errors (through trial and error) • Young children likely have multiple providers, multiplying the importance of fidelity.
Ways to Measure Fidelity • Development of fidelity checklists • Designed to ensure strategies are implemented correctly (adherence) and with high quality. • Adult Verbal Behavior • Adherence: Demands are limited to necessary behaviors, Child is reinforced with positive praise and attention and redirected with positive language, ratio of 4:1 is maintained • Quality: Praise is meaningful, is delivered in timely fashion and is behavior specific, Rate is increased prior to difficult tasks (build momentum). • TACSEI Family Coaching Checklist
Fidelity Measurement Exercise • You have a new interventionist that wants to teach a child how to make a PB&J sandwich. The parents are also very interested in teaching this skill. • Develop a checklist that will measure whether the parent and interventionist are teaching the skill the same way. • Focus on the environment, materials, prompting & steps. • Remember this is not a checklist of the steps needed to make a PB&J it is a checklist to help adults teach the skill with fidelity.
Data-based Decision Making • Why is this so important? • No evidence-based practice is universally effective. • Diversity within population implies that no one intervention will be universally applicable. • No existing technology to assess who will respond best to what intervention… Therefore ongoing data collection is the only alternative. • Provides unambiguous metrics of growth for consumers and multiple providers.
Examples of Easy to Use Data Systems 3 Screams Measuring Levels of Assistance/Prompting Measuring Behavior Change
The Data Process Modify Instruction
Data-Based Exercise Visually analyze the following data sets and determine your course of action.
Interpreting Your Data – Example 1 Data sheet measuring levels of assistance
Interpreting Your Data – Example 5 Target Behavior Key established for the behavior (based on baseline data): 5 = 16 or more times 4 = 9-15 times 3 = 5-8 times 2 = 2-4 times 1 = 0-2 times Behavior Rating Scales
What Do We Mean by Maximizing Outcomes Continued movement towards independence in functional skills and/or the reduction of problem behavior(s). Increased skills (both for children and parents).
