1、Behavioral Approaches to Early Intervention with Autism,WAYNE W. FISHERMunroe-Meyer Institute at the University of Nebraska Medical Center,Autism and Childhood Schizophrenia,Once thought to be a form of schizophrenia Differs from schizophrenia in terms of symptoms, age of onset, family history, etio
2、logy, and response to treatment,Definition of Autism,markedly abnormal or impaired development in:social interaction communication and markedly restricted repertoire of activities and interests.,Definition of Autism (continued),Definitions are cheap, but explanations are dear, and we must be careful
3、 not to confuse them. David Palmer, 2004,Autism Spectrum Disorders,Neurological disorders characterized by “severe and pervasive impairment in several areas of developmentAutistic Disorder Aspergers Disorder Childhood Disintegrative Disorder (CDD)Retts Disorder PDD-Not Otherwise Specified (PDD-NOS),
4、Prevalence of Autism,Typically diagnosed within first three years 2 to 6 in 1,000 individuals (Centers for Disease Control and Prevention, 2001) Four times more prevalent in boys than girls,NIH Research Dollars Devoted to Autism,When compared with other serious childhood conditions, autism is much m
5、ore common, but fewer dollars per case are spent on autism.,0,10,20,30,40,50,60,70,Autism,Juvenile Diabetes,Muscular Dystrophy,Leukemia,Cystic Fibrosis,Prevalence of Autism and Other Conditions (Number of Cases per 10,000 Children),$-,$20,000,$40,000,$60,000,$80,000,$100,000,$120,000,$140,000,Autism
6、,Juvenile Diabetes,Muscular Dystrophy,Leukemia,Cystic Fibrosis,NIH Research Dollars for Autism and Other Conditions (Number of Dollars per Case),Demographics of Autism,Knows no racial, ethnic, or social boundaries Family income, lifestyle, and educational levels do not affect the chance of autisms o
7、ccurrence Diagnosis of autism is growing at a rate of 10-17% per year (U.S. Department of Education, 2002),Assessment and Diagnosis of Autism,No medical tests for diagnosing autism Accurate diagnosis is based on observation of the individuals communication, behavior, and developmental levels. Autism
8、 Diagnostic Interview-R (ADI-R)Home and/or school observationVideo analysis of behavioral observation,Identifying the Genetic Bases of Autism Spectrum Disorders,Etiologic workups identify specific genetic causes for autism in about 20% of cases. At the Munroe-Meyer Institute, Dr. Schaefer and collea
9、gues (2006) developed a 3-Tiered Approach that identifies genetic causes in 40% of cases.,Early Screening for Autism (NICHD),Does not babble or coo by 12 months Does not gesture (point, wave, grasp) by 12 months Does not say single words by 16 months Does not say two-word phrases on his or her own b
10、y 24 months Has any loss of any language or social skill at any age,Early Screening for Autism (CHAT),Does not display pretend play (e.g., pretending to drink from a toy cup) Does not point at objects to indicate interest Does not show interest in other children Does not enjoy peek-a-boo hide-and-se
11、ek or other social games Does not bring and show objects to parents,Associated Disorders,Mental Retardation 70% 15% Seizure Disorder 35% 10%Self-Injury, Aggression 50% Tourette Disorder Bipolar Disorder,Autism ASD,Associated Etiologic Diagnoses,Fragile-X syndrome Tuberous Sclerosis Williams syndrome
12、 Landau-Kleffner syndrome Congenital Rubella Smith-Magenis syndrome Neurofibromatosis,Genetics and Twin Studies,Autism runs in families Heritability for autism is about 90% Monozygotic twin concordance, 60%-100% Dizygotic twin concordance, 10% Associated with abnormalities on chromosomes 7q, 2q, and
13、 15q,Applied Behavior Analysis (ABA),What is ABA? How is it different from other approaches? How is it done?,Baer, Wolf, & Risley (1968),APPLIEDstrives to produce rapid and clear benefit to problems of social importance; BEHAVIORALuses objective and accurate measurement of the behavior of interest;
14、ANALYSISuses controlled (single-case) methods to understand the environmental variable(s) that influence an individuals behavior.,Historical Roots of Behavior Analysis,1911 Thorndike-Law of effect 1924 Watson-Behaviorism 1927 Pavlov-Conditioned Reflexes 1938-Skinner Behavior of Organisms 1950s-Behav
15、ioral applications reported in scientific journals 1968-Journal of Applied Behavior Analysis,How Effective is ABA for Autism?,About 50% of Children with autism and mild mental retardation who received early intervention with ABA attain normal IQs and are educated in regular classrooms with minimal a
16、ssistance.,Outcomes of ABA for Autism,0,5,10,15,20,25,30,35,0,5,10,15,20,25,30,35,40,45,Hours per Week of Treatment,Increases in IQ Scores,r = .79,p .02,How Effective is ABA for Autism?,Early Intervention of Autism using ABA has been recommended by: New York State Dept. of HealthU.S. Surgeon General
17、National Research CouncilAssociation for Science in Autism Treatment,Why is ABA Effective?,ABA developed from and remains closely linked to basic research on the principles of learning and behavior. A central principle of ABA is called “Selection by Consequences.”In a given environment, behaviors th
18、at produce favorable outcomes are selected (or continue to occur) and those that produce unfavorable consequences are extinguished.,Why is ABA Effective? (continued),ABA has developed a wide variety of procedures for identifying the antecedents and consequences that influence behavior. We rearrange
19、the antecedents and consequences in the environment so that appropriate behavior is selected (or re-occurs) and problem behavior is extinguished.,Why is ABA Effective? (continued),Specific procedures includeShapingChainingPromptingFadingExtinctionReinforcementGeneralization strategies, etc.,Why is A
20、BA Effective with Autism?,Comprehensive: Teaches all skills (e.g., sitting, attending, imitating, direction following, language, social skills, self-help skills). Goal and Data Driven: The focus on objective measurement and analysis of behavior provides ongoing feedback on progress and setbacks.,Exa
21、mple of Individual Goals for Billy,Decease self-injurious behavior Increase eye contact Increase spontaneous requesting Increase labeling skills Increase use of yes and no Increase imitation skills Increase matching skills Increase letter identification Increase self-feeding skills,Teaching Imitatio
22、n Using Discrete Trials,Starts with simple responses (e.g., clapping). Sessions consisting of 10 trials; each trial starts with the therapist saying “Do this” and then modeling the target response. Any approximation of clapping, results in delivery of a preferred reinforcer (e.g., toy). Otherwise, t
23、he therapist guides the childs hands to complete the response and then begins the next trial.,Teaching Imitation Using Discrete Trials (continued),Once the first response is mastered, the same procedure would be used to teach a second response (e.g., waving). After two responses are mastered in indi
24、vidual sessions, they would alternately be presented in the same session (e.g., “Do this” clapping; “Do this” waving). Over time, additional responses are added until the child immediately imitates any new action the therapist does following the prompt, “Do this.”,Generalization of Skills,Skills tau
25、ght during discrete trials are then generalized to natural settings.e.g., Clapping when another child answers correctly during group instruction or at a recital or school assembly.e.g., Waving to another person when entering or leaving a room.,Billy: Imitating a Model,Why is ABA Effective with Autis
26、m? (continued),Empirical Emphasis: Treatments are based on principles and procedures supported by research. Intensity Level: 25 to 40 hours per week for 3 years.,Early Behavioral Intervention for Autism,Lovaas, 1987; McEachin et al., 1993; Smith et al., 2000 Year 1-reduce aberrant behavior, teach at
27、tending, imitation, instruction following, speaking in short phrases, play skills, and self-help skills,Early Behavioral Intervention for Autism (continued),Year 2-extend expressive vocabulary, more abstract concepts, extend treatment to group and community settings Year 3-pre-academic and academic
28、skills, appropriate emotional expression, observational learning, and interactions and friendships with normally developing peers,Cost-Benefit Analysis of Early, Intensive ABA for Autism,Average lifetime cost for a person with autism is over $4 million Average cost of Early, Intensive ABA is $150,00
29、0 over about 3 years Average lifetime savings from ABA Treatment is between $1.6 and $2.7 million,Assessing Children with Autism,Periodic assessment for diagnosis and management Ongoing assessment for intervention,Periodic Assessment for Diagnosis and Management,Identify the childs overall strengths
30、 and limitations Determine the appropriate diagnosis or diagnoses Set the global goals for treatment,Components of a Diagnostic Assessment,Genetic/Etiologic workup Assessment of behavior/symptoms Formal audiologic evaluation Cognitive testing Assessment of adaptive behavior Speech/Language evaluatio
31、n,Ongoing Assessment for Intervention,Identify the specific behaviors to be increased Identify the specific behaviors to be decreased Identify effective reinforcers,Assessment of Skills to Increase,Attending Skills Compliance Following Simple Instructions Motor Imitation Vocal Imitation Matching Pla
32、y Skills Social Skills Self-Help Skills,Skill Assessment Areas,Imitating Behavioral Chains Following Multi-Step Instructions Categorization Verbal Behavior-Listener Skills Verbal Behavior-Speaker Skills Pre-academic and Academic Skills,Matching Skills Progression,Identity matching with objects Ident
33、ity matching with pictures Matching pictures to objects Matching objects to pictures Matching shapes, colors, letters, numbers Matching on 2 dimensions (color-shape) Matching by categories (e.g., animals, vehicles) Matching objects with their spoken names Matching pictures with their spoken names,So
34、cial Skills Progression,Shaking hands Making eye contact during greetings Imitating a smile Smiling reciprocally Appropriately getting someones attention Appropriately exchanging toys with a peer Playing a simple interactive game (roll ball) Showing appropriate affection (e.g., hugs) Taking turns du
35、ring a simple game Making polite statements (e.g., “Bless you. “Your welcome.”) Initiating a conversation (e.g., “Did you watch the Huskers game?”),Preference Assessments,Children with developmental disabilities sometimes are not able to tell you what things they like or tell you when they want one
36、thing instead of another. Researchers have developed preference assessments to identify what things people with disabilities like.,Steps of Preference Assessments,Step 1: Interview the parent with the RAISD to list the kinds of things that the child likes Step 2: Get the actual items the parent nomi
37、nated as highly preferred Step 3: Allow the child to select items from the group Step 4: Rank the items from high to low based on what the child chose,Types of Preference Assessments,Single-item type Present each item from the group one at a time Choice type Present all items 2 at a time and let the
38、 child choose between the 2. Group type Present all items together and let the child select items from the group,Single-item Preference Assessments,Developed by Pace et al. (1985) 16 stimuli Each stimulus presented individually 10 times for 5 seconds each The SI method identified highly preferred st
39、imuli for all participants in the study However, subsequent research has shown that the SI method may also yield a high number of false positives,0,10,20,30,40,50,60,70,80,90,100,Toy Telephone,Radio,Barney Doll,Ball,Action Figures,Items,Percentage of trials chosen,Paired-Choice Preference Assessment
40、,Developed by Fisher et al. (1992, 1996) Take 5-10 top stimuli from the RAISD Each stimulus paired once with every other stimulus Two stimuli presented concurrently; the participant was prompted to choose one The participants had to emit a choice,Items,Percentage of trials chosen,Group Preference As
41、sessment- MSWO,Multiple Stimulus without replacement (MSWO) developed by DeLeon and Iwata (1996) Compared three different preference assessments (PC method, MSWR, & MSWO) Results obtained from MSWO were comparable to that obtained by the PC method,Items,Percentage of trials chosen,0,10,20,30,40,50,6
42、0,70,80,90,100,Toy Telephone,Radio,Barney Doll,Ball,Action Figures,Preference Assessment Outcome,Items that the child chooses are usually the most effective positive reinforcer.,Ongoing Preference Assessments,Paired-choice assessment conducted once every 4-6 months Mini-MSWO assessments conducted da
43、ily or more frequently,Compliance and Cooperation Training,Individuals on the autism spectrum often display problem behaviors in a variety of contexts including: when instructional requests are presented when asked to surrender an unusual object (e.g., piece of dirt) they are holding during instruct
44、ions,Compliance and Cooperation Training (continued),Teaching a child to accept removal of a preferred object using delay fading. Teaching compliance using least-to-most prompts.,Teaching Tolerance for Instructional Task,The traditional approach to treating these problems involves extinction Extinct
45、ion often produces deprivation from reinforcement, which in turn, may evoke bursts of problem behavior,Teaching Tolerance for Instructional Task (continued),Bouxsein and Fisher (in press) evaluated an alternative to extinction. The alternative involved the provision of a choice between surrendering
46、the preferred object or completing the instructional tasks while retaining the object.,0,20,40,60,80,100,1,3,5,7,9,11,13,15,17,19,21,23,25,27,31,33,Session,Percentage of Trials with Compliance,3-Step Prompting w/ Extinction,Baseline,Choice,Choice,29,3-Step Prompting w/ Extinction,0,20,40,60,80,100,1
47、,3,5,6,8,10,11,13,15,17,19,21,22,24,26,28,31,33,Session,Percentage of Intervals of Aggression and Disruption,3-Step,Choice,3-Step,Choice,Baseline,0,20,40,60,80,100,1,3,5,7,9,11,13,15,17,19,21,23,25,27,29,31,33,Session,Percentage of Intervals of Choice Allocation,Baseline,3-Step,Choice,3-Step,Choice,
48、Task Choice,Item Choice,Compliance Training,This case illustrates a simple and effective way to increase compliance while decreasing problem behavior associated with presentation of instructions This may be a result of decreasing the aversiveness of the instruction by allowing the child to choose wh
49、ether to surrender a object or complete an alternative demand,Improving Vocabulary Skills in Children with Autism,Recent behavior analytic work in autism has focused on teaching critical skills, ones that facilitate the acquisition of many subsequent skills (e.g., pivotal responses, behavioral cusps).,
