Ethan’s Case Intensive Early Intervention in BC

1. Ethan’s CaseIntensive Early Intervention in BC Presented by Pam Neuman & Anna Matchneva

2. Overview • Ethan • IEII and EAI funding • Treatment approaches • Recommendations and conclusions

3. Ethan • 5 year old First Nations boy, just diagnosed with Autism • Youngest of 3 children • Lives with Mom and boyfriend, Dad pays child support but is not involved • No speech, few vocalizations • Engages in high-rate self stimulatory behaviours, running back and forth, twirling plates and rocking • Poor eye contact, no play skills, and rarely initiates interactions with others • No self-care skills, eats only with hands, can not dress himself, not toilet trained • Frequent ear infections • Constantly tired –only sleeps 6-8 hours a night

4. Funding • (IEII) Interim Intensive Intervention funding • For kids with ASD 5 years of age and younger • Intensive, direct one-to-one intervention at home, in preschool and other community settings • Must follow best practice guidelines

5. Best Practice • Supportive, structured teaching methods, based on ABA • Functional assessment and PBS techniques for behaviour problems • Development of individualized plan of intervention • Use of multiple, integrated therapists • Integration in typical settings • Family involvement in training, development, implementation and review of interventions and plans • Transitions from preschool to Kindergarten • Trained staff, monitoring and yearly evaluation

6. Eligible Expenses • Goes directly to parents-to pay for costs of specialized behaviour treatment services • Parents choose qualified behaviour consultants, interventionists and therapists including SP’s, OT’s and PT’s from service provider list • Bookkeeper, accountant, or agency to assist with administrative tasks ($100 month) 8% of funding for agency

7. Parental Responsibilities • Parents determine amount of funding necessary needed-max. amount of $1667 per month-$20,000 per year-paid by either direct deposit or cheque • Open and maintain separate bank account in trust for child • Select behaviour consultants and therapists from the IEII qualified list • Select behaviour interventionists • Recruit, hire, fire, train, schedule and pay service providers • Criminal record checks • Ensure all service providers meet minimum requirements set out by agreement

8. Parental Responsibilities (Cont’d) • Manage funds, keep all financial records, invoices, receipts and bank statements • Submit monthly expense records to MCFD every 3 months • Provide copy of child’s intervention plan within 90 days of entering the contract • Submit final financial statement within 60 days of contract ending • Return any unused funds • Employee relationships, insurance, compliance with various employment acts, accurate tax payments

9. EAI(Extended Autism Intervention Funding) • For kids with ASD, 6-18 years of age • Used for intervention services for out of school • Must follow best practice-same as IEII

10. Eligible Expenses • Same as IEII funding • As well as dietary, nutrition counselling, family counselling/therapy, out of school learning support tutouring • Life/social skills trainer • Enrolment for specialized therapeutic recreational activities, specific to needs of the ASD child • Administrative costs$50 per month • 20% of funding an be used for training for parents, family members or interventionists • Travel costs, if appropriate • Equipment and materials related to intervention and recommended by a qualified provider

11. Parental Responsibilities • Same as IEII • Parents determine amount of funding needed-max. of $6000 per year-monthly payments or lump sum • Families can not get the EAI funding unless all terms and obligations of the previous IEII agreement have been met

12. EIBI Program(Early Intensive Behaviour Intervention) • Only for children with ASD in Delta, Victoria, and parts of the Okanogan • 20 hours /week 1-1 ABA highly structured intervention • Integrated with SP, OT, peer interaction, support for problem behaviours and family involvement

13. What is ABA? • Applied Behavior Analysis (ABA) is the science of human behavior and learning that began with the work of B.F. Skinner over 70 years ago. • Through many years of research in the field of ABA, we have learned that the important parts of the learning environments that we need to organize are: what we do to make the behavior occur what we do after the behavior occurs to make it stronger in the future • This process of arranging antecedents and consequences is the basic unit of teaching children with autism. • ABA views autism as a syndrome of behavioral deficits and excesses, which can be changed with careful programming. • It is important to understand that ABA is a framework for the practice of a science and not a specific program.

14. Discrete Trial Training (DTT) DTT involves: • breaking a skill into smaller parts • teaching one sub-skill at a time until mastery • allowing repeated practice in a concentrated period of time • providing prompting and prompt fading as necessary • utilizing reinforcement procedures SIMPLY A WAY OF GOOD TEACHING

15. Treatment Approaches Based on Applied Behavior Analysis (ABA) • Lovaas • Verbal Behavior (VB) • Natural Language Paradigm (NLP) • Pivotal Response Training (PRT) • Precision Teaching – Fluency

16. What is Lovaas? • In the 1987, Dr. Ivar Lovaas demonstrated a successful use of discrete trial training with individuals with autism within a specific early intensive behavioral program. This program is often referred to as the Lovaas Method Lovaas,O.I. (1987) Outcome: 47% achieved IQ scores in the normal range and completed first grade in a regular classroom without support McEachin, Smith, Lovaas (1993) Follow up indicated that 8/9 individuals maintained the pattern into adolescence Eikeseth, Smith, Jahr, Eldovick (2002) Compared Intensive Behavioral treatment and Eclectic approach with 4-7 year olds with autism IB group obtained average scores above the E group on all measures except Vineland Socialization

17. What is Lovaas? (Cont’d) Program: • 40 hours / week for 2 years • 1:1 teaching • Intervention team • Adult directed • Trial-by-trial data • Emphasizes attention, compliance, and imitation skills in the beginning of the program • Language training through vocal imitation

18. What is VB? • Verbal Behavior (VB) is a specialty within the field of Applied Behavior Analysis (ABA). • VB is based on B.F. Skinner’s analysis of verbal behavior, which looks at the functions of the different verbal operants (units of language). Mand request (MO = strong), first verbal operant acquired Receptive understanding of language Tact labeling Intraverbal ability to talk about items / events that are not present = ability to have a conversation FFCs (R, T, I) identifying item by it’s description rather then it’s name Sundberg (2001) The Benefits of Skinner’s Analysis of Verbal Behavior for Children with Autism.

19. What is VB? (Cont’d) • VB addresses difficulties in the development of communication seen in most individuals with autism, in part by emphasizing functional language and tying it to motivational variables. • The behavioral analysis of language separates the components of language into several verbal operants, which enables us to more specifically target language deficits and ensure that a student is utilizing language in its functional context. • The teaching involves creativity and flexibility in order to move with the student’s motivational variables. • Instructors must be highly skilled in order to accommodate this flexibility while continuing to target the necessary skills, which are the focus of the particular student’s curriculum. • Research by DRs. Sundberg, Partington, Carbone, McGreevy, Michael, et al. in JAVB and JABA

20. VB Research • Drash (1999) Using mand training to establish an echoic repertoire in young children with autism 3 nonverbal children with autism 2.5 – 3.5 years old Establishing a mand repertoire as the starting point for echoic training produced the acquisition of an initial echoic repertoire in all 3 children within the first 10 sessions 2 aquired tacts during this period • Arntzen and Almas (2002) Effects of mand – tact versus tact-only training on the acquisition of tacts Results indicate that mand-tact training established both verbal operants as rapidly as tact-only training established only one verbal operant

21. Intervention Program Utilizing Analysis of Verbal Behavior • Adult directed (Intensive Teaching) + Child directed (Natural Environment Teaching) • DTT (clear instruction, consequence for responding, and prompts to help ensure success) • Student’s learning must be fun and motivating to all involved • The number of hours of therapy is not as important as the number of active responses that occur during that time taking into account the motivational conditions under which those responses occur (Sundberg & Partington, 2003) • Language development through mand training • Assessment of Basic Language and Learning Skills (ABLLS) Assessment instrument which provides a precise measurement of a student’s existing skills and the conditions under which the skills are being utilized and an instant tracking system to continually measure learning achievements. • 1:1 teaching / group instruction /adopted by schools in US • Probe data

22. Intervention ProgramUtilizing Analysis of Verbal Behavior (Cont’d) Teaching techniques: • Pairs teaching environment with reinforcement • Mix and vary instructional demands • Errorless Learning • Intersperse easy and difficult demands • Teach to fluency

23. Verbal Behavior (Cont’d)What is NET? • NET was developed by Dr. Sundberg and Dr. Partington. • Focuses on a child’s immediate interests and activities as a guide for instruction. • It is conducted in the child’s typical daily environment rather than in formal teaching arrangements. • Many different teaching techniques, including DTT, can be used in the NET environment. • Advantages of NET include: Optimal conditions to teach manding, the use of stimuli in the natural environment as target SDs, the reduced need to elaborate generalization procedures, the naturalistic instructional context, the ease of teaching intraverbal behavior. • Disadvantages: Requires better training on the part of staff, curriculum is not scripted and it is difficult to follow child’s EO to know what to teach, measures of acquisition

24. What is PRT? • Pivotal response training (PRT) is a behavioral treatment intervention based on the principles of applied behavior analysis (ABA) and derived from the work of Koegel, Schreibman, Dunlap, Horner, and other researchers. • Pivotal behaviors are central to a wide area of functioning, so positive changes in these behaviors produce improvement across a number of other behaviors (Koegel, Koegel & Carter, 1999). • Key “pivotal behaviors”: Motivation Responsiveness to multiple cues Self-management Initiation of interactions • Teaching pivotal behaviors involves DTT (clear instruction, consequence for responding, and prompts to help ensure success)

25. What is PRT? (Cont’d) • PRT is an intervention that typically developing children can use to assist their peers with autism to attend to and maintain effective social interactions. • Generalization to new toys and new adults as well as the maintenance of improved play behaviors has been seen in children who have participated in PRT (Schreibman, Stahmer, & Pierce, 1996). • Research is currently being conducted which assesses ideal child characteristics for PRT. Pilot data suggests that there are some children that are better candidates for PRT than others: “Children perform best in this type of training who interact with toys and who do not have an extreme amount of self-stimulatory behavior that does not involve objects” (Sherer and Schriebman, 1998)

26. PRT Research • Stahmer (1995) Teaching Symbolic Play to Children with Autism using PRT 7 children with autism (language skills of at least 2.5 years) Used PRT to teach engagement in symbolic play 8 weeks / 3 1-hour session per week All of the children learned to perform complex and creative symbolic play actions at levels similar to that of language-matched typical peers Skills generalized to new toys and new setting Increased interaction skills • Shaw (2001) Behavioral Treatment for Children with Autism: A Comparison between DTT and PRT in teaching Emotional Perspective-taking Skills 6 children with autism DTT vs PRT: treatment effectiveness, overall improvement, rate of skill acquisition, generalization and maintenance DTT showed increased treatment effectiveness in skill acquisition PRT showed increased treatment effectiveness in generalization and maintenance Results for treatment effectiveness were inconsistent due to individual differences

27. PRT Research (Cont’d) • Koegel, Bimbella and Schreibman (1996) Collateral Effects of Parent Training on Family Interactions 4 scales: level of happiness, interest, stress, and style of communication PRT parent training paradigm resulted in families showing positive interactions in all 4 scales and generalization to daily life

28. Components of PRT Program • Choice (shared control to increase motivation) • Clear and uninterrupted instructions or opportunities • Reinforcement of approximations/attempts • Reinforcement has a specific relationship to the desired behavior • Natural reinforcement ("ball" gets ball, not praise) • Child chooses object for instruction • Multiple examples or multiple components presented (e.g., use two different objects but same verb such as "roll car" and then "roll ball“) • NLP used to teach language • Implemented by parents and peers

29. What is NLP? • Builds upon arranging the environment to increase opportunities to use language • Instructor follows child’s lead, choice, or interest "Children with autism have also been shown to be more successful in learning initial words and language and to engage in longer periods of sustained conversational interaction when their interests are considered." (Koegel, 1995) • Structure is taught during natural play interaction • Language targets are presented in the context of the activity that the child is involved in • Teaching multiple exemplars in natural environments to provide for generalization • Instructions are similar to ones that child will encounter in everyday interaction • Reinforces speech attempts • Emphasis on turn taking and ongoing interaction between the teacher and the child as mutually active partners

30. NLP Research • Koegel, O’Dell & Koegel (1987) A Natural Language Teaching Paradigm for Nonverbal Autistic Children 2 nonverbal children with autism Analogue (DTT) vs NLP Both children showed more imitative utterances with NLP Children demonstrated generalization to spontaneous utterances only with NLP Generalization of clinical gains occurred in other settings for both children with NLP • Delprato (2001) Comparisons of DTT and NLP for Young Children with Autism 8 studies with language-criterion responses showed that NLP was more affective then DTT • Laski, Charlop & Schreibman (1988) Training parents to use the NLP to increase their autistic children speech Parents of 4 nonverbal and echolalic autistic children Following training, parents increased frequency at which they required their children to speak

31. What is Precision Teaching? • PT is not a method of instruction as it is a precise and systematic method of evaluating instructional tactics and curricula (West & Young, 1992) • PT does not prescribe what should be taught or how to teach it: The instruction can be by any method or approach • The most effective applications of PT have been when it is combined with Direct Instruction (Johnson, 1989) • Key elements of PT framework: pinpointing of target behaviors analysis of instruction and the type of response required importance of fluency building upon fluent pre-requisite skills

32. What is Precision Teaching? (Cont’d) • PT, as an addition to any educational program, provides sensitive and precise measurement, real-world mastery and instructional options (Kerr, Smyth & McDowell, 2003) • Learner knows best: if a student is progressing according to plan, then the program is appropriate for that student; otherwise, there is a flaw in the program and it needs to be changes in some way • Standard Celeration Chart : precise tool to record student’s performance

33. What is Fluency? • Fluency describes the behavior that is flowing, accurate and seemingly effortless (Kerr, Smyth & McDowell, 2003) • Fluency is a combination of speed and accuracy that characterizes competent performance (Binder, 1998) • Many students with autism miss social and educational opportunities because of their long latencies to respond (Weiss, 2002) • Fabrizio & Schirmer (2002) Teaching Visual Pattern Imitation to a Child with Autism single case study of a 5 years old boy with mild autism taught to identify and complete visual patterns in a relatively short time

34. Comparison Overview

35. Comparison Overview (Cont’d)

36. Comparison Overview (Cont’d)

37. Other Interesting Research • Kamps (1990) A Comparison of Instructional Arrangements for Children with Autism Served in a Public School Setting 3 elementary school students with autism one-to-one vs small group teaching word recognition skills small group allowed for more trials and reinforcing statements closely approximating regular classroom activities • Bertsch (2003) A Comparison of One-to-one and Small Group Instruction for Young Children with Autism: Focus on Effective Teaching and Behavior Management SG is more efficient and effective than 1:1 small group instruction offers fewer direct learning opportunities SG: faster rate of acquisition, more efficient in term of time and resources

39. Behavioral Approach Social-Pragmatic DTT Developmental Approach <___L______VB_____PRT_____ ___________________________> Teacher Parent <___L______________VB_______________PRT______________> Every day use Training Data collection Time

40. Service Availability Service Provider Availability L = 5 VB = 1 PRT = 1 PT-F = 1 Training L = 3 VB = 1 PRT = 1 PT-F = 1 Behavior Interventionists L = 3 VB = 1 PRT = 1 PT-F = 1 Financing L = 5 VB = 4 PRT = 2 PT-F = 4 Network Support L = 5 VB = 3 PRT = 1 PT-F = 1

41. Recommendations:Hopeful Ideologies… • “…we can optimize research and practice by reminding ourselves not to put all of our “eggs” (i.e., resources, hopes) in any single procedural basket. People with autism, like all of us, must learn to learn in a variety of ways: from direct instruction; from incidental teaching; from television, videotape, and computer; from parents, teachers, peers, and employers; and from pictorial, auditory, and textual cues. There are various intervention procedures, all firmly grounded in science, that accomplish these different but equally important objectives. The most important aspect of these procedures is their scientific underpinnings. The challenges are to support and promote intervention efforts that reflect the array of contemporary, empirical based procedures and to teach discrimination among scientific and unscientific approaches to treatment. (Krantz, 2000) • Service provider utilizing a variety of scientific approaches and fitting a curriculum and instruction to the child and not a child to the curriculum and instruction • 1-stop shop, full meal deal/all-inclusive plan-an organization that takes care of everything for the family with therapists that use a multi-treatment approach

42. Recommendations: Reality Check • Does not exist here in B.C. • Only treatment available that can suit this child’s immediate needs is Lovaas • 28-30 hours a week one-to-one therapy-service provider must use “The New Me Book”

43. Other Recommendations • Family should interview the therapists and ask the following questions….. • Goodness of fit, that takes into consideration the cultural ecology of the family, 2 siblings, parent involvement etc. • Preschool-integrated • Good paediatrician who has experience working with children with developmental disabilities • Immediate referral to an ENT doctor • Family support institute, ASBC, MMOM, ACT-BC • Bookkeeper and extension of the funds for additional 6 months

44. Choosing an ABA Provider • MCFD Service Provider Qualifications: Graduate degree in related field • Behavior Analyst Certification Board (BACB) www.bacb.com • Guidelines for choosing and ABA provider developed by FEAT – Greater Bay Area www.php.com/feat.htm

45. What questions should I ask? • Where and by whom were you trained? • Do you network with other professionals? • Do you have experience working with my child’s level and age? • What stages of therapy have you been involved in? • What kind of assessment do you do and how do you train parents and other staff? • How many children do you serve? How many hours can you work with my team? • Do you develop programs to assist with self-help and living skills? • How do you keep current in the field? • Etc