You Got to Have Friends! Developing Appropriate Social Skills in Students with Learning and Behavior problems

1. You Got to Have Friends!Developing Appropriate Social Skills in Students with Learning and Behavior problems Bob Babcock, Ph.D., BCBA Coordinator of Psychological and Outreach Services, The Learning Tree, Inc. Private Practice

2. Why is this so hard??? • Humans don’t come with a schematic diagram ….. Although we are getting much better information about functional neurophysiology every day • People are really complicated …. (Self-evident on Valentine’s Day) • The old saw about how: “Everything I needed to know in life I learned in (perhaps before) Kindergarten” seems loosely correct. • Unfortunately, we usually have the most trouble with folks who are don’t have good social skills long after the age of 6.

3. Kids and adults with autism spectrum disorders as a model for extreme difficulties with social skills (sung to the tune of “New York, New York, if I can make it there I can make it anywhere, ”) • Diagnostic criteria: • Qualitative deficits in social functioning • Impairments in language • Restrictions in the range of interests • Increasingly identified • Including Asperger’s Syndrome the prevalence of people on “the spectrum” may be much higher than the 1/150 recently announced by CDC

4. Current findings in the neurobiology of autism: • Both the medial temporal lobe (MTL), including the amygdala, as well as the cerebellum, have been found to be abnormal in several studies (Akshoomoff, Pierce & Courchesne, 2002; Dawson et al., 2002). • A striking recent finding is increased brain volume when children with autism are young, although not at birth or later in life (Aylward, Minshew, Field, Sparks, & Singh, 2002), leading to a theory of brain growth dysregulation underlying autism (Courchesne et al., 2002).

5. Abnormal processing of Information in facial recognition tasks with adults • fMRI study of differences B.O.L.D. between S’s with ASD and comparison S’s. • Slides presenting facial discrimination tasks to subjects • S’s are asked to identify as same or different Schultz, Gauthier, Klin, Fulbright, Anderson, Volkmar, Skudlarski, Lacadie, Cohen, & Gore (2000)

6. Fusiform gyrus hypoactivity in facial information processing tasks • Replicated across labs – hence reliable • Conceptually important as it relates directly to the development of • Shared attention, • Joint eye contact, • Recognition of emotional states of others, • Social intuition. • Combined with decreased time ASD subjects spend looking in the eyes of faces of others suggests persons with ASDs are compensating in social tasks for a specific neurological weakness

7. Evidence of partial impact of normal social experience in remediation • Children with autism show the now classic pattern of fusiform hypoactivation first seen by Schultz and others to faces of strangers • They show normal patterns of fusiform activation to facial expressions of the mothers and siblings However…..

8. Beneath fusiform gyrus hypoactivity lies fear…. • Dalton et al (2005) used neuroimaging procedures from Shultz, et. al (2000) and others and examined correlation between diminished eye gaze in facial recognition tasks and BOLD level measures of activation in medial temporal lobe. • Decreased eye contact correlated with hypoactivation in fusiform gyrus • Decreased eye contact correlated with HYPERACTIVATION in areas of amygdala associated with negative emotion!

9. Autism Severity correlates with FunctionalAbnormalities In Temporal Lobe • Meresse, et al (2005) Studied blood flow at rest in 45 CWA, average age 7.9 years, using whole brain covariance analysis to assess the relationship between clinical profile on the ADI-R and blood flow • A significant negative correlation was found between rCBF in the left superior temporal gyrus and ADI-R scores. • The more severe the autistic syndrome, the lower rCBF is in this region -- suggesting left superior temporal hypoperfusion is related to the severity of autistic behavior. • In the dominant hemisphere the superior temporal lobe is involved in language and has been implicated in social perception of biological movement, including movements of the eyes, mouth, hands, and body. Ann Neurol 2005;58:466–469

10. Kids with ASDs in residential schools are kids with huge deficits in social skills • Typically get to residential schools by exhibiting severe problems with aggression, elopement, self-injurious behavior, deficits in communication skills, etc. • Criteria for placement – Community schools can’t provide FAPE because of the severity of maladaptive behavior patterns • Usually, school and home environments of these kids are so far from what they need that anything less restrictive than placement would be too risky

11. The Learning Tree, Inc. – A residential school-based program in Alabama • Begun as a private, non-profit school for kids with intellectual challenges, communication difficulties and challenging behaviors • Educational program licensed/funded by the Alabama SDE • Home-life component certified/funded by the Alabama DMHMR. • Begun as a non-profit organization in the Mobile County in1983 by three parents of multiply-handicapped children to establish an environment to nurture, challenge, and provide individualized instruction. • The goal was to provide their children with a quality education focusing on strengths and using those strengths to develop skills.

12. Strong organizational commitment to only offering empirically validated treatment (i.e., applied behavior analysis and conservative empirical psychopharmacology for treatment ) • In 23 years of service, the school has grown from four students and two staff persons at one school in Mobile; to over 80 students and over 350 full- and part-time staff at 3 residential campuses. • Currently 17 full-time BCBA-level staff are administrative, clinical, and teaching roles across all programs • Currently training 14 master’s level graduate students at Auburn University providing BCBA practicum supervision, and training 5 undergraduate BCABA-level students at JSU • Outstanding university-affiliated psychiatric and neurological services (Roy Sanders, MD-Marcus, Manuel Cepeda, MD-Univ. South Alabama, UAB neurology) • We don’t permit SI, AI, diet, or other “alternative” autism interventions at any of our schools

13. Instructional services • Residential programs have, at most, 3 children in a group-home setting staffed by educationally-oriented direct-care (ISPs are developed using CALS) • TLT school environments are staffed between 1:1 and 1:3 (IEPs are developed using the ABLLS and CALS) • Behavior analysis procedures are implemented across both school and home environments • FBAs are all direct, typically descriptive, and use brief FAs when clear and consistent hypotheses do not emerge from FAI and structured observations • All treatment evaluation is data-driven with ongoing, but not always adequate, monitoring of IOA and treatment integrity • Placing students in our local community schools is an increasingly common outcome for our kids – most of whom are long-term (until 18 or 21)

14. Costs of Residential Education • $95,000 to $232,000 • source: Lexington public schools • Projected median cost for student entering residential at 11 years of age. • $163,500 per year • Costs probably average well above the median for programs providing appropriate services • Once residential placement occurs, coming home may not be an easy thing to do….. • When schools place a child and costs are picked up by the state, few rush to welcome these kids back • When parents experience that they can’t keep a child at home and go through the separation of putting him/her in residential home placements may not longer be realistic • When kids are “fixed” in a residential placement, this does nothing to educate the community school and home to prepare for return

15. Costs of Placement in a Residential School for ASD (if placed from 10-22 years, $1,962,000)

16. Program Development Efforts • We serve approximately 35 children across over a dozen school systems throughout Alabama seeking to prevent residential placements • Most referrals come through attorneys wanting to settle cases they would otherwise fight at the school’s and child’s expense • We serve 8 children (2.5 yrs-5yrs) with autism in an intensive ABA and inclusion-based preschool affiliated with Auburn University (The Little Tree Learning Center) • We provide training for personnel in community schools at our preschool for personnel through the ACORN program (see a theme here?)

17. The Little Tree Learning Center • Preschool program for CWA and typical kids • Incidental teaching, peer modeling, and peer tutoring supplemented with discrete trial training if needed • CWA included in regular classrooms except when 1:1 is needed for types of instruction we can’t provide with typical peers • Data driven intensive ABA intervention with a minimum of 150 learning opportunities per hour and progress on all programs within 2 weeks required • ABLLS used as primary but not exclusive curriculum • All procedures selected for the individual child justified by published ABA literature

18. Promoting Social Behavior • Language development occurs in play interactions • Peer interactions are expected from the earliest of ages – not deferred until the child is “ready.” • Peer tutoring is explicitly used to develop social behavior • We are pushing for earlier rather than later admission to services.

19. Monthly Levels of Change for Children at The Little Tree

20. The ACORN Project • Assisting • Children to • Overcome with • Research findings & • Nurturance

21. How it Works -- • Training is available throughout the year • We begin with an initial assessment of children selected by the school using the ABLLS. • Personnel and parents participating in the program come to the Little Tree Learning Center in Auburn, an inclusive model preschool program, for training in basic ABA procedures for implementation in their local settings. • We the train adults by emersing them in our preschool as interventionists in a 2-5 day experience with children and programs selected to develop their use of improved early intervention skills back home. • After the training we provide on site consultation to begin programs and supervise the use of newly learned skills.

22. At The Little Tree • Participants receive competency-based training in selected core-skill areas that are essential components of behavioral instruction for children in a preschool environment. • Examples of these skills include: • Incidental teaching of language and social skills • Attend and ignore (behavior management) • Maintaining functional engagement • Finding and using reinforcement effectively • Effective prompting strategies

23. Comprehensive Behavioral Support Program (aka School Consultation)

24. Ages of Students Served Median age ~11.5

25. Diagnoses of Students Served

26. Services Provided

27. Severity of Behavioral Issues Presented by Students

28. Functional Behavioral Assessment • Descriptive • Interview • Observation • Ecological Data Analysis • Analogue • Brief FAI • Extended FAI • Demonstrating Functional Relations in Treatment

29. Plus an FBA and a Behavior Support Plan we often… • Review the IEP for how well the students social, motivational, communication, life skill, and academic deficits are addressed • Conduct the CALS and other assessments depending on the situation • Select new IEP goals that can result • Functionally equivalent replacement skills (better communication, social and negotiation skills) • Self-management skills • Train teachers in specific instructional techniques needed by challenging students • Set up OBM systems to involve the school’s administration in reinforcing (with attention and praise) the implementation of positive behavioral support plans • Set up videotape or other monitoring systems to permit consultant to monitor, evaluate, and provide feedback to teachers and others on correct and incorrect use of teaching and behavior support program techniques

30. Tools: • Consent to share information with school and parents on an equal footing • CALS • FAI, NSA • Eco-Behavioral Assessment System • Standardized format for managing individual data spreadsheets • Email with password protected files as attachments • Competency-based training, using video modeling and video feedback • Videotape monitoring of teaching skills, Engagement, and Program implementation • Celeration charts for fluency-based training

31. A Typical Positive Behavioral Support Program • Functional Behavioral Assessment – Interview and Observations • Hypothesis about Function and Skills to be Developed • Data Collection Method • Current Behavioral Levels • Behaviors to Strengthen • Behaviors to Weaken/Eliminate • Objectives • Reinforcement Procedures • Responding to Problem Behaviors • Procedures for Data Review • Parental Consent

32. Social Skills Training Embedded in Positive Behavior Support Plans • Quite Hands (personal space) • Polite Voice • Listening to the teacher • Sharing things with other students • Participating in group activities • “Stop-Freeze” • Accuracy in reporting rule following • Making mistakes without melting down over them

33. Techniques teachers can use to promote appropriate social behavior in schools • Direct instruction in role play activities (giving teachers scripts to use to coach specific skills) • Self management training – reviewing positive classroom rules and reinforcing both behaviors consistent with positive rules and do-say correspondence (giving teachers cues to use to provide reinforcement for appropriate behavior) • Pivot praise – prompting by reinforcement of peers for appropriate social behavior combined with differential reinforcement (giving teachers a method for responding to problem behaviors without directly reacting to them) • Positive scanning (Prompting teachers to see and reinforce god behavior) • Beat the timer – providing teachers with both flexibility and structure (giving teachers a system to prompt use of ALT-R techniques while ensuring the rate of reinforcement remains adequate) • NETO – providing a stimulus as a prosthetic response and cue to children about contingencies (giving teachers a way to manage extinction, time-out, and negative reinforcement of good behavior without inadvertently reinforcing problem behaviors) • Peer mentoring groups and adult mentoring of acceptance of one’s limitations for kids with ADHA, etc.

34. Typical Examples of Outcomes… • 1 5th grade child re-entered school after 16 months at home • 2 high-school students successfully moved to regular education • 2 high-school students received reasonable accommodations and needed nothing else (not kids with autism) • 1 5th grader removed from a single inclusion class by parent during baseline • 2 children with autism fully included in regular Kindergarten with behavioral intervention instead of being in a segregated “preschool.” • 2 First-grade students included in regular education with pullouts, instead of being in self-contained with dramatically decreased aggression and sib • 2 students with Asperger’s provided with support in regular education – 1 needing a BSP, the other being assisted with teacher training • 1 High-school student provided with a completely revised IEP • 4 students maintained in current setting with behavior support plans decreasing aggression, SIB, etc.

35. Behavioral Coaching Adolescents and Adults • Social deficits are more responsible for unemployment that a lack of technical job skills • Interviewing for a job can be harder than doing one • Stress in work and social situations can result in avoidance behavior patterns • Unskilled interactions with law enforcement personnel can be hazardous • Intimate relationships must be built upon both competent judgment and information about • Biology • Emotional attachments • Legal issues • What our Momma would think about it if she knew what you two were up to…

36. Strategies • Addressing functional but counterproductive ASD specific patterns of social behavior with a conceptual FA • Identifying natural contingencies and educating the person about what to expect • Instructing new behavior patterns through coaching (Risley’s macro level of intervention) • Instructing self-management skills such as relaxation • Arranging short-term goals and short term contingencies to help individuals experience success and eventually meet longer-term goals • Teaching parents and other support providers to use positive scanning to reinforce progress in social functioning. • Developing self-managements plans negotiated with significant others • Helping people that provide support to persons with challenges become objective consultants, rather than providers of consequences • Helping people identify their limitations and to explain how a reasonable accommodation would permit them to be successful at work and in social settings • Helping people building a philosophy of rules in specific areas (e.g., dating) from experience (using the EAB findings on rule-governed behavior and persistence)

37. Bottom lines • People manipulate their social environments – those who cannot live with “learned helplessness.” • There isn’t anything wrong with being in control of your environment • There are good behaviors and bad behaviors – but labeling them so and punishing bad behaviors doesn’t teach good behaviors • People who lack social skills can learn to not behave through punishment – but learning a new skill requires effective prompting and reinforcement • We know much more about how to shape and mold new behaviors than we are willing to apply when we believe that social failures reflect motivational problems • Being raised right only works (when it does) for kids who don’t need much more than reasonable adult models. • Most adults deal with kids the way they were dealt with as children • An enormous number of kids need a lot more instruction than we realize when they screw up on issues that are social in nature. • You don’t resolve a “can’t do” problem with a strategy focused on motivational issues, errors, and failures. All you teach that way is that adults “Don’t get it.” • If you assume the problem is a skill deficit then there is, after all something you have to teach a child other than that they are a failure.