Evidence-Based Practices for Teaching Skills to School-aged Children and Youth with ASD

1. Evidence-Based Practices for Teaching Skills to School-aged Children and Youth with ASD Candace A. Fugazy MA.Edu, BCBA

2. Agenda • National Standards Report Review • Errorless learning/prompting • Social Stories • Contingency mapping • Peer Mediated Model

3. What is the National Standards Report (NSR)? • The NSR is the most comprehensive analysis available regarding treatments for children and adolescents with autism spectrum disorder (ASD). • Project started by the National Autism Center in 2005 with the guidance from an “expert” panel comprised of nationally recognized scholars, researchers and other leaders representing diverse fields of study including, BCBA’s, Ph.D.'s, SLP, MD’s, MA’s.

4. What is the NSR? • The project examined and quantified the level of research supporting interventions that target individuals with ASD. • Over 775 articles of behavioral and educational literature were reviewed between the years 1957-2007. • All articles focus on treatments with individuals with autism prior to age 22 • This will now allow families to find specific information on certain age groups, treatments and different populations treatments have been used on.

5. The initiative of this report is to: • Provide the strength of evidence supporting educational and behavioral treatments that target characteristics of autism. • Describe age, diagnosis, and skills/behaviors targeted for improvement associated with treatment options. • Identify the limitations of the current body of research. • Offer recommendations for engaging in evidence based practice for ASD.

6. Effectiveness of treatments are broken into four categories: Established: Sufficient evidence is available to confidently determine that a treatment produces beneficial treatment effects for individuals on the autism spectrum. That is, these treatments are established as effective. Emerging: Although one or more studies suggest that a treatment produces beneficial treatment effects for individuals with ASD, additional high quality studies must consistently show this outcome before we can draw firm conclusions about treatment effectiveness.

7. Effectiveness of treatments are broken into four categories: • Un-established: There is little or no evidence to allow us to draw firm conclusions about treatment effectiveness with individuals with ASD. Additional research may show the treatment to be effective, ineffective, or harmful. • Ineffective/Harmful: Sufficient evidence is available to determine that a treatment is ineffective or harmful for individuals on the autism spectrum.

8. Established Treatments • Antecedent Package (99 studies): Modification of situational events that typically precede the occurrence of a target behavior to increase the likelihood of success or reduce the likelihood of problems occurring. Represented by research in the fields of ABA, behavioral psychology and positive behavioral supports. • Examples include but are not restricted to: behavior chain interruption (for increasing behaviors); behavioral momentum; choice; contriving motivational operations; cueing and prompting/prompt fading procedures; environmental enrichment; environmental modification of task demands, social comments, adult presence, intertrial interval, seating, familiarity with stimuli; errorless learning; errorless compliance; habit reversal; incorporating echolalia, special interests, thematic activities, or ritualistic/obsessional activities into tasks; maintenance interspersal; noncontingent access; noncontingent reinforcement; priming; stimulus variation; and time delay.

9. Established Treatments • Behavioral Package (231): Interventions designed to reduce problem behavior and teach functional alternative skills through application of behavior change procedures. Represented by research in the fields of ABA, behavioral psychology and positive behavioral supports. • Examples include but are not restricted to: behavioral sleep package; behavioral toilet training/dry bed training; chaining; contingency contracting; contingency mapping; delayed contingencies; differential reinforcement strategies; discrete trial teaching; functional communication training; generalization training; mand training; noncontingent escape with instructional fading; progressive relaxation; reinforcement; scheduled awakenings; shaping; stimulus/stimulus pairing with reinforcement; successive approximation; task analysis; and token economy.

10. Established Treatments • Comprehensive Behavioral Treatment for Young Children (22 studies): Researched basedtreatment programs involving a combination of ABA procedures delivered to children under the age of 8 (DTL, Incidental teaching, etc.). Treatment delivered in variety of settings and involve low student to teacher ratios. All studies comprise of targeting the defining symptoms of ASD, having treatment manuals, high intensive treatment and measuring effectiveness of programming.

11. Established Treatments • Joint Attention Intervention (6 studies): Building foundation skills involved in regulating the behavior of others. Examples are teaching the child to respond to the nonverbal social bids of others or to initiate joint attention interactions,pointing to objects, showing items/activities to another person, and following eye gaze. • Modeling (50 studies): Demonstrating a target behavior to be imitated by the student. Can include simple and complex behaviors. Often combined with other strategies such as reinforcement and prompting. Live and video modeling included.

12. Established Treatments • Naturalistic Teaching Strategies (32 studies): Using child directed interactions to teach functional skills in the natural environment. May involve, modeling how to play, encouraging conversation, providing choices and direct/natural reinforcers and rewarding reasonable attempts. • Peer Training Package (33 studies): Teaching typical children strategies for facilitating play and social interaction to children on the spectrum. May include components of other treatment packages including self-management for peers, prompting and reinforcement.

13. Established Treatments • Schedules (12 studies): Presentation of a task list that communicates a series of activities or steps to complete an activity. Often supplemented by reinforcement or other interventions. Photos, words line drawings. • Self-Management (21 studies): Treatment involves promoting independence by teaching how to self-regulate behavior by recording the occurrence/non-occurrence of the target behavior and reinforcing. Student is taught to independently seek and/or deliver reinforcement. • Story Based Intervention (21 studies): Written description of situations of which behaviors are expected to occur. May be supplemented with prompting, reinforcement or discussion.

14. Established Treatments • Pivotal Response Training (14 studies): focuses on targeting “pivotal” behavioral areas such as motivation to engage in social communication, self-initiation, self-management, and responsiveness to multiple cues, with the development of these areas having the goal of very widespread and fluently integrated collateral improvements. Key aspects of PRT intervention delivery also focus on parent involvement in the intervention delivery, and on intervention in the natural environment such as homes and schools with the goal of producing naturalized behavioral improvements. This treatment is an expansion of Natural Language Paradigm which is also included in this category.

15. Break Down • Pattern of findings suggests that treatments from behavioral literature have the strongest research support at this time. • Note: Alternative theory based treatments in isolation or combined with behavioral treatments should continue to be examined empirically.

16. Emerging Treatments • Augmentative and Alternative Communication Device (14 studies) • Cognitive Behavioral Intervention Package (3 studies) • Developmental Relationship-based Treatment (7 studies) • Exercise (4 studies) • Exposure Package (4 studies) • Imitation-based Interaction (6 studies) • Initiation Training (7 studies) • Language Training (Production) (13 studies) • Language Training (Production & Understanding) (7 studies) • Massage/Touch Therapy (2 studies)

17. Emerging Treatments Cont. • Multi-component Package (10 studies) • Music Therapy (6 studies) • Peer-mediated Instructional Arrangement (11 studies) • Picture Exchange Communication System (13 studies) • Reductive Package (33 studies) • Scripting (6 studies) • Sign Instruction (11 studies) • Social Communication Intervention (5 studies) • Social Skills Package (16 studies) • Structured Teaching (4 studies) • Technology-based Treatment (19 studies) • Theory of Mind Training (4 studies)

18. Treatments Discussed Today • Prompting Strategieshttp://www.youtube.com/watch?v=7S07DN4I4bo • Errorless Learning • Contingency mapping • Peer mediation • Social Stories

19. Errorless Learning Techniques • Errorless learning is a set of prompting procedures are used to ensure correct responding and to eliminate errors when teaching new skills. • “Errorless learning” is not a set technique but rather implementing varied types of prompts to maximize learning and decrease incorrect responding used in conjunction with positive reinforcement. • Students are given the highest level of prompting when starting a new skill and prompts are systematically decreased (Most-to-least).

20. Using errorless learning offers the following benefits: • Minimizes the number of errors • Reduces frustration and the occurrence of maladaptive behaviors by increasing opportunities for reinforcement • Increases overall time available for instruction • Reduces the likelihood that errors will accidentally be learned repeated in future trials.

21. Using Errorless Learning Has the Following Challenges: • Challenging to avoid all errors. • Does not teach individuals to deal with failure in a positive manner. • Programming for errorless is time consuming. • Note: make sure that the function of your student’s errors are not due to inattention or boredom.

22. Physical Prompting • Full physical- hand over hand • Partial Physical- lighter, fading touch • Touch- one finger • Most-to-least/Least-to-Most

24. Verbal/Auditory • Full verbal- give answer • Partial verbal- saying part of answer • Sound- initial sound of answer, timer http://www.youtube.com/watch?feature=endscreen&v=jW6UHOJ-Kxg&NR=1

26. GraduatedGuidance-full guidance is provided immediately, but faded immediately contingent upon correct responding - used often with task analysis

28. Visual Prompts • Gestural: pointing or motioning to object, miming action. • Positional • Modeling (live, video) • Photo • Line drawing: text, Boardmaker, etc.

29. Within-Stimulus Prompt • Alters the SD by changing the stimuli to highlight the correct answer (size, position, shape, color, etc.)

30. Extra-stimulus prompt • Adding supports to highlight an SD, a template to help the learner determine where to put something, arrows pointing to the correct answer, etc.

31. Extraneous Prompts • Can be hard to fade because reinforced so much. • Student might not actually be learning the skill.

32. Prompt Fading • Prompts should be faded to avoid prompt dependency. • Fade systematically • Determine how the prompt will be faded before you start fading. • Begin fading when correct responding averages 80% correct. • 2-3 consecutive incorrect responses return to the last prompt level that the student was successful

33. Ways to Fade Prompts • Delayed Prompt: increasing time between the SD and the prompt. • Example:

34. Teacher: “What is the word for the number 2 in Spanish?” (pause) “Uno, (pause, no answer), “Dos.” Student: “Dos.” Teacher: “Muy bien!” Teacher: “What is the word for the number 2 in Spanish?” (pause, no answer) “Uno,” (pause) “do---” Student: “Dos.” Teacher: “Muy bien!” Teacher: “Number 2?” (pause, but student murmurs numerals in Spanish); then says “Dos.” Teacher: “Dos. Muy bien! So how many fingers am I showing you?” Student: “Dos.” Teacher: “Muy, muy bien! Dos.”

35. Ways to Fade Prompts Cont. • Stimulus Fading: “Artificial or intrusive prompts are gradually and systematically removed for the purpose of enabling control of transfer to the antecedent stimuli that are supposed naturally to control the response.” - Mayer, Azarof, Wallace (2012).

38. Prompt FadingGestural Prompts Trainer Student

39. Prompt FadingGestural Prompts Trainer Student

40. Prompt FadingGestural Prompts Trainer Student

41. Prompt FadingGestural Prompts Trainer Student

42. Prompt FadingPositional Prompts Trainer Student

43. Prompt FadingPositional Prompts Trainer Student

44. Prompt FadingPositional Prompts Trainer Student

45. Prompt FadingPositional Prompts Trainer Student

46. Social Stories • Developed by Carol Gray in 1991. • Assists students in learning the perspectives of the individuals they are interacting with and developing a greater social understanding. • A short description of a particular event or activity offering specific information on what to expect and why. • The goal of a Social Story is to reveal accurate social information in a clear and reassuring manner that is easily understood by the individual.

47. Social Stories • To develop self-care skills (e.g. how to clean teeth, wash hands or get dressed), social skills (e.g. sharing, asking for help, saying thank you, interrupting), sexuality, etc. • To assist an individual to cope with changes to routine, and unexpected or distressing events (e.g. absence of teacher, moving house, thunderstorms). • To provide positive feedback to an individual regarding an area of strength or achievement in order to develop self esteem. • As a behavioral strategy (e.g. what to do when angry, how to cope with obsessions).

48. How Are Social Stories Helpful to Individuals With ASD? • Information is presented in a literal, concrete and accurate manner, which may aide in the individual’s understanding of a previously difficult or ambiguous situation or activity. • The visual presentation of Social Stories utilizes the preference for visual processing experienced by many individuals with ASD.

49. How Are Social Stories Helpful to Individuals With ASD? Con’t. • Provides information about what to expect in a particular situation and guidelines for the individuals own behavior in a format that is meaningful and relevant. • Social Stories can increase structure in the individuals life and thereby reduce anxiety. • Assist with sequencing (i.e. what comes next in series of activities) and executive functioning (i.e. planning and organizing).