2021 Metro Speech-Language Symposium Diagnostic Criteria for Spectrum Disorder Disorders: (DSM-5; 2013) • A. Persistent deficits in social communication and social From Diagnosis to interaction across multiple contexts, as manifested by the Practical Strategies for Success following, currently or by history: • Deficits in social-emotional reciprocity, ranging, for Scott Schwartz, Ph.D., CCC/SLP example, from abnormal social approach and failure of University of Colorado-Boulder normal back-and-forth conversation; to reduced sharing BVSD of interests, emotions, or affect; to failure to initiate or [email protected] respond to social interactions.

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• Deficits in nonverbal communicative behaviors used for B.Restricted, repetitive patterns of behavior, interests, or social interaction, ranging, for example, from poorly activities, as manifested by at least two of the following, integrated verbal and nonverbal communication; to currently or by history: abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of 1. Stereotyped or repetitive motor movements, use of facial expressions and nonverbal communication. objects, or speech 2. Insistence on sameness, inflexible adherence to routines, • Deficits in developing, maintaining, and understand or ritualized patterns of verbal or nonverbal behavior relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to 3. Highly restricted, fixated interests that are abnormal in difficulties in sharing imaginative play or in making intensity or focus. friends; to absence of interest in peers. 4. Hyper-or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.

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C.Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). • Note: Individuals with a well-established DSM-IV diagnosis of D.Symptoms cause clinically significant impairment in social, autistic disorder, Asperger’s disorder, or pervasive occupational, or other important areas of current functioning. not otherwise specified should be given E.These disturbances are not better explained by intellectual the diagnosis of autism spectrum disorder. disability (intellectual developmental disorder) or global developmental delay. • Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism Severity is based on social communication impairments and spectrum disorder, should be evaluated for social (pragmatic) restricted, repetitive patterns of behavior. .

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1 ASD Level 3: “Requiring Very Substantial Support” ASD Level 2: “Requiring Substantial Support”

• Severe deficits in verbal and nonverbal social communication skills • Marked deficits in verbal and nonverbal social communication skills; cause severe impairments in functioning, very limited initiation of social impairments apparent even with supports in place; social interactions, and minimal response to social overtures from • limited initiation of social interactions others. • reduced or abnormal responses to social overtures from others. • Few words of intelligible speech • Rarely initiates interaction • Makes unusual approaches to meet needs only and responds to only very • Inflexibility of behavior, difficulty coping with change, or other direct social approaches. restricted/repetitive behaviors appear frequently enough to be • Inflexibility of behavior, extreme difficulty coping with change, or obvious to the casual observer and interfere with functioning in a other restricted/repetitive behaviors markedly interfere with variety of contexts. Distress and/or difficulty changing focus or action. functioning in all spheres. Great distress/difficulty changing focus or action.

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ASD Level 1: “Requiring Support” Biological Basis of Autism • Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions and • Structural neuroimaging in “Infant sibling study design”. High Risk-ASD clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social • 15-20 fold greater risk of younger sibling of child with autism also having autism than the general population interactions. • Brain differences and changes are present during the period in ASD before • Able to speak in full sentences and engages in communication diagnosis and precede (or coincide with) behavioral differences. • To and fro conversation with others fails • For HR-ASD, head size is normal at birth, but by 2 to 3 years of age, head • Attempts to make friends are odd and typically unsuccessful. circumference and total brain volume is significantly enlarged compared to • Inflexibility of behavior causes significant interference with non ASD. functioning in one or more contexts. Difficulty switching between • Extra CSF in brain surrounding the cortex for those later diagnosed with activities. Problems of organization and planning hamper autism. The amount of CSF at 6 months preceded symptoms and predicted independence. a diagnosis of ASD and severity of ASD.

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Synapse Pruning Differences Cognitive Domains • Pruning: Researchers believe that children with autism might not • Sensory system- Hypo and hyper-sensitivity; multisensory undergo the regular synapse pruning process during early brain coordination and integration development that occurs in typical development. • Motor-fine motor, gross motor, gait, movement (hand, body, • Ralph-Axel Müller SDSU: “Impairments that we see in autism seem to be partly due to different parts of the brain talking too much to each etc.) other,” he said. • Social Skills- theory of mind, play, interaction, • “You need to lose connections in order to develop a fine-tuned system of brain networks, because if all parts of the brain talk to all • Perception; Object recognition; auditory, visual, sensory parts of the brain, all you get is noise.” • Organizational strategies (hyper or disorganized?) • Attention and concentration; Selective; shifting; divided;

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2 • Emotional regulation- Ability to calm emotions, appropriate Spectrum, not a Continuum emotions for situation, anxiety, calmness, control, inhibition system • Memory- Working memory; short term, long term; episodic; • Patterns of performance and profiles of strengths and deficit areas are retrieval (language, concepts, academics) consistent with a variety of different neurological and neuropsychiatric • Executive functioning; Reasoning; Problem solving; judgment; conditions. planning • Deficits in emotional regulation, high anxiety, sensory processing, • Processing speed pragmatics, conversational skills, motor skills, organization, disruptive • Language/verbal skills; nonverbal skills; , semantics, outbursts, etc. pragmatic skills, conversational skills, • Gifts in memory ,focus, detail, visual perceptions, organization, pattern • Academics recognition, specific interests, innovation, etc. and comprehension (specific interests). Math; word problems

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Auditory • Hypo or hypersensitive to certain frequencies, loudness levels or The Senses and Autism sounds. • Auditory • Auditory processing • Visual • Figure ground (can’t parse sounds out of the environment) • Touch • Temporal processing of sound • Intensity and frequency are not processed typically • Smell and taste • Agnosia (can not process what you are hearing) • Does not habituate to sounds

• Any of the senses might be the most reliable for the individual • Certain noise that bothers you? Noises that increase your anxiety? • Hypersensitivities- overly sensitive • Neighbor dog barking, leaf blower, nails on a board, nails on certain plastics, certain voices, ? • Hyposensitivities- low sensitivity compared to typical • Whine of computers, florescent bulbs, heater, wind, running water, radiator, vacuum, etc.

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Visual Touch • Hypo or hypersensitive to brightness, colors, changing lights • Hypo or hypersensitive to heat, cold, pain, texture, pressure • Visual processing • Processing touch • Figure ground • Whole system is overwhelmed by certain touch (can not sense • Overly attracted or intolerant to movement or describe the issue) • Visual agnosia (processing what you see, video screen, pictures) • Feel sensation but do not connect it to themselves • Face recognition • Pain does not register as pain • Averted gaze or lack of eye contact. • Soft feels like sandpaper

• What distracts, increases your anxiety by way of touch? Tag in your shirt, lint in your • Visuals that might bother you? Fluorescent lights, reflections, sock, wooden spoons, wool, someone touching your hair, masks? flickering, movement or wiggling of someone? • Shoelace too tight, clothes rubbing, someone touching you, etc.

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3 Smell and Taste Synesthesia

• Hypo or hypersensitive to certain smells and tastes • Intermingling of the senses • Processing of smells and tastes • 1) seeing sounds • Use tongue and nose often and inappropriately (eat inedible objects, smell everything) • 2) tactile stimulation triggers auditory sensation • Might only eat certain foods; taste, texture, sound • 3) tasting colors; words or numbers have colors (Born on a Blue Day; Daniel Tammet) • Oversensitivity to smell might cause adverse reaction; • 4) In Mind of a Mnemonist (Luria) ,the mnemonist describes how he refusal to go into room, PE, kitchen, art, science, etc. • a) perceived tones through pictures and taste • b) voices took on certain colors What smell do you love or hate? P.E., art, coffee, cleaning supplies, newly cut • c) clouds and line splashes would occur when sounds were heard lawn, certain foods, bodily fluids, new car, shampoo, perfume? • d)These were consistent; just like red looking always like red to us. What taste or texture? Red onions, crunchy, sticky candy, garlic, flan, mint, chocolate, coconut? 19 19 20

Other Behaviors That We Observe Why do these behaviors exist?

• Creating predictability in an unpredictable world • Insistence on sameness • Create systematic order to reduce anxiety • Difficulty with Transitions • Reaction to overstimulation, change in environment, • Nonfunctional manipulation of objects (twirling your unpredictable situation causing cognitive dissonance. hair?) • Internal explosion- , anxiety attack • Self Stimulatory Behavior • Release energy to reduce anxiety • Repetitive language (song stuck in your head?) • Escape into own world • Fulfill sensory needs • Aggression • • Unmanageable behavior

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Types of Diagnosis Factors in Increased Prevalence of ASD Diagnosis • Medical Diagnosis -Uses criteria from DSM-5 • Child Psychologist, Child Psychiatrist, Pediatrician (with training in autism), • Diagnostic Shift-The changing nature and interpretation of the diagnosis of multidisciplinary team in hospital or clinic (SLP, OT, PT, etc.) ASD • Educational Identification- Eligibility; impact on learning (behavior); • Diagnostic Reclassification- One diagnosis to another due to shifting are services required. Criteria defined by state. pattern of diagnosis and overlap with other disorders • School psychologist, SLP, SpEd teacher, OT, PT, parent, specialized team, etc. • Diagnostic Capture- The increased awareness of ASD in the general • Political (financial)- Diagnosing for services (Diagnosing for Dollars) population and more referrals for assessment (internet) • Same people as above • Incentive for diagnosis- Treatment incentives and funding for getting a • Maybe not all criteria are met for ASD, but enough so that child can receive diagnosis of ASD services in school or through insurance. Fewer symptoms, same diagnosis. • Better gathering of information and reporting to appropriate agencies. • More children have ASD.

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4 Changes in Number of Symptoms to be Diagnosed Symptoms and Signs That Motivate with ASD Referral for ASD Evaluation

• Over time, fewer symptoms were required to get a diagnosis of ASD • Delayed language • Difficulty with transitions • Study (Sweden) investigated ‘Autism Symptom Score’ necessary for • Delayed development • Need for predictability an ASD diagnosis between 2004 and 2014. • Communication delays • Anxiety • Sensory input issues • Social reticence • The 2004 cohort of children diagnosed with ASD between 7 and 12 • Poor eye contact • Uncooperative behavior had twice as many symptoms as the 2014 cohort. (mean Autism • Lack of sharing • Impulsivity Symptom Score went from 8.6 in 2004 to 4.6 in 2014) • Echolalia • Challenging behavior • The 2004 cohort of children diagnosed with ASD between 0-6 had • Motor • Mood swings the same number of symptoms as the 2014 cohort • Repetitive movement or motor • Shutdowns or meltdowns behaviors • Emotional regulation • Narrow range of interests • Self injurious behavior • Adherence to rituals or routines

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Diagnoses that are Mistaken for Reasons for Misdiagnosis or Comorbid with ASD • • • Inexperience, lack of information or bias toward finding ASD. • Developmental delays • Attachment Disorder • • Language delays • Not competent at differential diagnosis; don’t know the other • Late Talker • ; Antisocial Personality options. Did not explore long enough. • Speech delays Disorder • Not using an informed team approach (some teams are biased). • Mental Illness • Social Pragmatic • Setting of situation. Unfamiliar testers (many) and observers in • • ADHD room. Child shuts down….looks like ASD. Not listening to parent. • • Surgically induced brain injury High intelligence • • Obsessive Compulsive Disorder • Oppositional Defiant Disorder (ODD) No input from school if tested at a clinic. Child is quite talkative and • Body Apraxia • Trauma (PTSD) appropriate given the adult context and knowing what the correct • answers are……does not look like ASD.

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Social Relatedness, Social Interaction and Social Examples of Social Relatedness Understanding • • Issues with social relatedness are the most pervasive, defining Sharing of enjoyment and emotion with gaze, eye contact. characteristic of ASD • Shifting of gaze from toy to person. • Social affect and engagement, social learning, social-emotional • Looking and smiling at person while watching toy. reciprocity, recognizing and using social cues • Responding to name. • Joint attention; initiating and responding. • Request for help from person, not hand (using person as a tool). • Begins in first 6-10 months • Pretend play; feeding a baby, making food, stuffed animals play. • Social coordination of visual spatial sharing • Social coordination of mental attention (common point of reference) • Using toys as intended; stacking, nesting, toy cars, telephone, push toys, • Interpersonal coordinated information processing balls, etc. • Necessary for learning, interacting, engaging, peer relations, • Not based on intellectual abilities. Children of lower intellectual abilities etc. have better joint attention than children with ASD and higher ability.

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5 Social (Pragmatic) Communication Disorder DSM-5 3. Difficulties following rules for conversation and A. Persistent difficulties in the social use of verbal and storytelling, such as taking turns in conversation, rephrasing nonverbal communication as manifested by all of the when misunderstood, and knowing how to use verbal and following: nonverbal signals to regulate interaction. 1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is 4. Difficulties understanding what is not explicitly stated appropriate for social context. (e.g., making inferences) and nonliteral or ambiguous 2. Impairment in the ability to change communication to meaning of language. match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language.

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• B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic Social Communication Disorder vs. ASD achievement, or occupational performance, individually or in combination. • Overlapping symptoms in social skills. C. The onset of the symptoms is in the early developmental period • Yes, difficulty in social relatedness, interaction and social (but deficits may not become fully manifest until social understanding. communication demands exceed limited capacities). • Yes, delayed milestones or unexpected first communications, limited D. The symptoms are not attributable to another medical or intentions, different gesturing, etc. neurological condition or to low abilities in the domains of word • NO restrictive or repetitive behaviors. structure and grammar, and are not better explained by autism • Often diagnosed in school age as social interactions become more spectrum disorder, intellectual disability (intellectual developmental challenging. disorder), global developmental delay, or another . • Asperger? • PDD-NOS?

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Similarities Between Late Talkers Late Talkers and ASD vs Typical • Toddlers who appear to be developing normally but do not begin • Less interested in interaction speaking, acquire words more slowly and do not begin combining words at a typical age. No words by 18 mos. • Less apt to initiate communication • One in ten children start talking late • Rate of communication is low • 70% do not have autism or any other lasting language or • Range of sounds and words produced is similar developmental disorder by age 4 • Use of gaze to regulate interactions is limited • For others; it could be language disorder, speech disorder, intellectual • Ability to share emotions with others disability, or autism as a reason for continued delay. • Of the children diagnosed with autism by 2 years old, one in three • Ability to engage in back and forth interaction loses that diagnosis by age 4.

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6 Differences Between Late Talkers vs. ASD Late Talkers and ASD at 3 Years • Late talkers have better receptive language and responding • Children with ASD have more receptive language difficulties • Late talkers use appropriate gesturing • Children with ASD might demonstrate failure to respond to • Late talkers demonstrate pretend play and appropriate use of toys name and other verbal attempts at gaining attention and objects • Lack of expression of joint attention in ASD • Late talkers have social relatedness and understanding. • Unusual non-communicative vocalizations in ASD • When speaking begins, children with ASD demonstrate prosodic • Failure to coordinate gaze gesture, vocalization and facial differences and more echolalia. expression in ASD • Lack of social relatedness skills

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Social Anxiety Disorder vs. ASD

• Social situations cause extreme anxiety and fear; physical symptoms • ASD is in all situations and pervasive. (e.g., blush, sweat, feel ill, rapid heart rate) • Social anxiety can appear typical with good social relatedness in • Fear of being center of attention; feel embarrassed and awkward. familiar comfortable situations (with family, close friends, etc.) • Avoid meeting new people; avoid contact with people in community; • Motivation to social avoidance in Social Anxiety is fear; in ASD might avoid asking questions; avoid crowds, avoid public restrooms, avoid be disinterest, sensory issues, not knowing how to engage. eating in front of others, avoid eye contact, etc. • Autism has self stim behavior, repetitive behavior, self help skills • Difficult time meeting and keeping friends. deficits, unexpected responses, etc…Social Anxiety does not. • Afraid of being judged by others • ASD does not have the skills to make friends, Social anxiety might have the skills but is afraid to try.

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High Intelligence High IQ and ASD

• Highly motivated to learn more about their interests. (music, • Can be comorbid. computers, chess, volcanoes, art, coding, space, maps, etc.) • High IQ might not conform to traditional social norms. • Obsessive interests that monopolize conversations. • High IQ might have good conversational skill and social relatedness when at • Difficulty with social interaction with peers; hard to find common their level on a variety of topics. They appear typical, interactive, turn ground (topics, conceptual level of topics, vocabulary). taking, social. • Aware of others but not really interested in their interests. • High IQ look more typical as they find their cohort in upper grades. Think of the 4 year old with High IQ. • Difficulty being wrong or hearing others that are wrong; inflexible, will • ASD have difficulty with change, poor eye contact, social humor, affect, heatedly and enthusiastically argue their point (which can cause verbal proxemics, often have motor clumsiness, impaired conversational skills, and physical conflict). more restricted interests, repetitive play, prosodic differences in speech. • General and social anxiety; social engagement can be overwhelming. • ASD often has more scattered skills in intelligence testing

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7 ADHD (ADD) vs. Autism Differences Between ADHD and ASD In DSM-4, ADHD and Autism could not be comorbid • ADHD: might want friends but because of behavior, friends might not • Easily distracted by extraneous stimuli; fiddling with everything want him. Behavior, aggression, interruption, lability, etc. • Easily distracted by internal distractions (own thoughts, obsessive • ASD: might not show interest in interacting; when interacting, topics, etc.) difficulty with the rules of conversation, only talk about own • Difficulty staying focused or changing focus (Legos) interests., nonresponsive to others. • Constant motion; unable to sit still • ADHD has more typical play skills, pretend play, social responsiveness, • Interrupts and intrudes inappropriately joint attention, direct gaze, shared enjoyment. • Difficulty with social interactions, peer relations • ASD has more repetitive behaviors, insistence on sameness and social communication issues. Social relatedness. • Over or under response to stimuli • Emotionally labile; wide and quick mood swings

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Conduct Disorder vs. ASD (Called Antisocial in Adults) Conduct Disorder Characteristics • Superficial similarities in behavior • Often bully, threaten or intimidate others with intention to • Both have difficulty with social interaction and perception of hurt others (emotionally). others. • Destroy property to cause damage with intention • Both might appear quirky in their responses and actions • Lie to obtain things or get out of trouble or blame others • Both might have concrete thinking. • Both might appear to want to be by themselves, not engaging • Show a lack of remorse for doing something wrong others. • Show a lack of empathy for others who they might have • ASD can get labeled as behavior problems or conduct disordered. done wrong Must look at intention and motivation.

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Obsessive Compulsive Disorder Multiple Disabilities • OCD and ASD can have similar characteristics such as repetitive behaviors, lining objects up, insistence on sameness, anxiety over change, touching/tapping, etc. • High IQ and ADD • For ASD, these behaviors can keep order and soothe. They might be • Social Anxiety and based on sensory or motor input, predictability. • • For OCD, these behaviors are a result of a compulsion to get rid of Conduct Disorder and High IQ anxiety ; the behaviors will keep bad things from happening and • Conduct Disorder and ADD must be done. (hand washing, checking, arranging, apologizing, counting, etc.) • High IQ and social anxiety • OCD is rare before the age of 5, often start in . • Etc. • Social Relatedness is mostly typical in OCD, during non OCD times. • Still not necessarily Autism Spectrum Disorder

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8 Dunning Kruger Effect Thoughts on Diagnosis

• It is a slippery slope to a diagnosis of ASD for many children who show behavioral issues, developmental or language delay or social-interaction differences. • Explore other possibilities beyond ASD or maybe comorbid with ASD. • Autism should not be an end point but a start to determine other possible genetic, developmental, hormonal, psychological, environmental, gastrointestinal, etc. causes.

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Assumptions About Children with Autism A Brief History of Autism

• Responding/adapting to their environment in the best way they know Interventions how. • Prior to the 1960s, children with (classic) autism were believed to be unreachable, would not respond to therapy. • Trying to be competent in a world that is difficult to understand. • Electroshock, physical punishment, hallucinogenic and other medications • Trying to reduce their inner anxiety through their behavior. were tried. • Trying to create predictability in an unpredictable world. • 60s and 70s (Skinner) brought on operant learning and saw that children can learn new skills in language, social, self help, and reduce interfering • Presenting with sensory processing deficits, confusion, intolerance. behaviors. Applied Behavioral Analysis began; “the science of how organisms learn.” • Not being malicious with their behaviors; usually a brain based reason for dysregulation and high arousal states. • Lovaas (1987) in his study made claim of “recovery” and that children became “apparently normal children”. (by forcing a change in a child’s • Looking at me and trying to understand me and my perspective of the outward behavior it can effect an inward psychological change.) world as intensely as I am looking at them and trying to understand theirs.

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History of Autism Interventions And on The Other Side of Town……

• Most ABA programs used discreet trial training (break skills down • Explosion of research into typical infant and child development; into components and teach in discreet trials until skill is acquired). cognitive science. • Discrete presentation of information, prompted response, extrinsic • Developmental learning processes, language, social and cognitive positive reinforcement (treat, hug, tickle, sticker) development. • Highly structured contexts in isolated clinical contexts. • Research into the typical sequence of learning language, , social skills, adaptive skills, attending • BCBA starts in 1998; prior to that anyone could hang a shingle behaviors. • Now some programs are based on “Verbal Behavior” and use the • Research into how and where children learn best; environment, VBMAPP for evaluation and generating goals.(Skinner, 1957). people, context, affective engagement, motivation.

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9 Developmental Research: Developmental Models of Sequence and Milestones Working with Children with Autism

• Precursors to language; intention, joint attention, social engagement, imitation • Child is an active participant in learning through interactive exploration of • Language is driven by (supported by) cognition; it is abstract and symbolic. their natural environments and experiences. • Language is based on intention, emotion, motivation, social interaction. • Work begins at child’s developmental level in each domain. • Language develops in a predictable sequence. • Social relationship and affective engagement are how children learn. • Language development (receptive and expressive) ; syntax, morphology, • Working on core deficits through child initiated and adult arranged semantics, pragmatics, speech sound development (repertoire of intentions) interactions (communicative temptation or need). • Emotional Regulation; temperament; frequency of and recovery from tantrums, • All communicative attempts are responded to and encouraged. meltdowns by age (and personality). • Emotional expressions are exaggerated by the adult. • Social skills development: eye contact, attention to face, interaction, symbolic play skills, conversational skills, theory of mind • Language and interaction are adjusted to facilitate communicative growth.

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Floortime Naturalistic Developmental Stanley Greenspan Behavioral Interventions (NDBI) • -Relationship (parent/therapist/) based therapy. Start at • Coined in 2015 article with multiple authors from different theoretical developmental level of child. Engage child, follow their lead. backgrounds. • Works on self regulation; joint attention, engagement; language • Combines the behavioral and developmental theories of learning and development; emotional thinking, complex communication within development. context. • Learning targets from all domains; language, social, cognitive, motor. • Encourages inclusion with typically developing peers in preschool • Context of reciprocal, coordinated play is meaningful, social settings. interactions; motivating play routines, emotionally robust. • Child taps on cars, you tap on truck; then trade. Then introduce • Teaching includes modeling, prompting, fading prompts, chaining, airplane; then introduce ramp. Tap, tap, tap, slide. Tap, tap, tap, slide etc. red car, blue car. Then slide, and put in garage, slide and put in red car in garage, etc.

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Naturalistic Developmental The SCERTS Model Behavioral Interventions (NDBI) Prizant, Wetherby, Rubin and Laurent • Social • Three part contingency; Antecedent, Behavior, Consequence in looking at behaviors and planning goals. Communication • Skills are chosen from developmental sequence and presented in • Emotional naturalistic environments using natural rewards. • Measurement of progress through data collection Regulation • Environmental arrangement and natural contexts to enhance learning. • Transactional • Natural reinforcements related to the activity or task. (not extrinsic) Support Three areas that must be focused on for individuals with autism.

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10 The SCERTS Model Emotional Regulation

• Framework to coordinate services to address core challenges in area • The ability to independently attain an optimal level of arousal. of Social communication and emotional regulation. • Optimal level of arousal; available for engaging others and learning. • Family-professional partnership • Must bring child to optimal level of arousal for receptivity. • Developmentally based- coordinated assessment process for • Being receptive to partners to help you attain the optimal level. determining baseline and progress • Having consistent, respectful, trusted, support when dysregulated. • Can incorporate other models: NDBI, ABA, TEACCH, Floortime, , etc. • Children are less available due to caused by sensory confusion and difficulty predicting other’s intent. • Focused on applying learned skills in multiple settings with a variety of people.

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Behavior Modification or Why is the Child Teaching Emotional Regulation? Demonstrating these Behaviors? • Attention seeking, sensory seeking, escape, access to tangibles • Avoiding an upcoming event (PE, Music, Recess, Class, etc.) • or • Assignment or task is too difficult. • Neurologically based brain difference, sensory overload, intrusive • Doesn’t understand assignment/task; Doesn’t know how to start; Doesn’t thoughts, transitions, not understanding the language, social expectations, know what is expected; Doesn’t know sequence, Doesn't know when intention, etc. assignment/task is over. • Rewards are not strong enough or absent. No intrinsic reason for doing task. • Children are not adults; we often assign adult intention and motivation to what children are doing • Difficulty attending; difficulty transitioning (visual supports). • Overwhelmed by language/directions. • Children communicate through behavior; Children want to be competent. • Over stimulating situation (look at all sensory stimulation in environment) • The teacher/therapist/parent’s attitude and perspective can change the outcome in the long term. Punitive or supportive? • Needs sensory input (jump, flap, run, squeeze, rock, hand/arm movements.) • Having own thoughts, intrusive, repetitive, playing movie or words in head.

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Autistic Behaviors or Thought on Improving Behavior Human Behaviors • Don’t take it personally (which might be difficult when a child’s • Flapping, running away, touching, jumping, rocking, echoing, teeth are implanted in your arm). meltdowns, poor eye contact, adherence to rituals, lack of sharing, etc. • If you have been trying something and it is not changing behavior, • What purpose does it serve? Why are they doing these behaviors. Have more of the same is not going to help; try something different. you ever tried them? Have you asked the child? • You need to de-escalate as a child escalates; you should become • People are whole, embrace differences. Not fixing something broken. more technical and less emotional or tap someone else in. • What do we do to the child (self concept, trust, respect) by constantly • Our job is to help the child learn how to regulate his or her own trying to extinguish “maladaptive, abnormal” “autistic behaviors”? emotions and behaviors. • Think Trauma Informed Care; not “What is wrong with you?” but “What • We need to provide replacement behaviors. happened to you?” or “What is going on inside of you?”

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11 Transitions Nonfunctional Manipulation of Objects • Might need a reason to move to next activity Self Stimulatory Behaviors • Strategies for getting through transitions • Moving objects in ways in which they were not intended and are not • transition warnings (use timers), Three minutes until clean up time, two functional: minutes until clean up time • Spinning wheels on truck, Twirling objects, Ripping magazines, Banging • transition signals; songs, lights out and lamps on, objects, • Start talking about (not asking) and showing visuals from next activity; • sequences Visual-body or object movements in front of eyes • objects, having student bring something appropriate to next activity or • Auditory-creating or listening to sounds bring something to next teacher. • Motor/vestibular-flapping, bouncing, rocking • Pictures of next activity to keep student focused on what is next. • • distraction- take child’s mind off of what they are doing and where they are Tactile-tapping, rubbing, Self Injurious Behaviors (SIBs) going by discussing favorite things • What need is being fulfilled? What is the purpose?

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Unmanageable Behavior Early Start Denver Model • Tantrums (purposeful; child wants something) vs. Meltdown (sensory; Rogers and Dawson emotional overload). • Explicitly incorporates play-based developmental interventions with ABA in • Hitting, pinching, biting, chinning, head butting, grabbing, scratching, etc. naturalistic settings. • Reaction to overstimulation, change in environment, unpredictable • Designed for children in the infant, toddler and preschool period. situation, etc. Inability to communicate (tired, hungry, thirsty, • The adult and the child create something that is interesting for both. disappointed, cold) Taught in a positive, affect based relationship. • Might be communicative; Might be attempt at being interactive • Children with autism are on a typical developmental trajectory but at different points than same age peers in different domains. • Internal explosion- panic attack, anxiety attack. • As early as possible, parent training on ABCs and development; look at all • Fight-Flight-Freeze possibilities for what triggers behaviors. (Parent coaching: 12 weeks) • Be aware if you are escalating a behavior with your response. • Expand and elaborate repertoires in motor, language. Flexibility of routines with objects, people, places, • Protect yourself, dress appropriately.

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TEACCH Treatment and Education of Autistic and Related Priorities of TEACCH Communication Handicapped Children • 3 Necessary skills for independence and workforce: • Developed in 1972 ; by Shopler at University of North Carolina • Appropriate Behavior • Approach (not program) that incorporates visually based systems to facilitate • Following a sequence independence. (Home, classrooms, work, life skills, leisure, domestic.) • Attending/Completing task • Arrangement of physical environment, structured teaching, work systems, • Focus is on skills, interest and needs , sequences and communication. • Creates adaptations and systems for individuals to facilitate success • Based on learning strengths and profiles of children with autism; visual processing, consistent routines, difficulty with executive function. • Strength based; not deficit based (what is the student good at?) • Increases predictability, teaches transition skills, reduces • Works closely with families • Can be used at all levels in all areas; academics, communication, vocational, • Accepts person with autism for who they are recreation, coping, strategies.

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12 TEACCH Systems Visual Supports Systems

• Visually based systems to facilitate independence • Many of us use some visual supports; few of • Structured teaching use many. • Up in space systems; what do you do when you are not sitting at a • Visual supports are any visual table? representations that assist in: • Arrangement of physical environment • communication • Creates work systems • organization • sequencing • Visual schedules, sequences and communication • memorization • choices • following rules • etc. 73 73 74

How Do Visual Supports Help? How Do Visual Supports Help?

• Support weak auditory processing system by using stronger visual • Organizational cues system • Creates predictability in environment • Gives a stable stimuli and time to process (rather than transient • Helps with transitions nature of acoustics) • Increases language usage • Reduces anxiety and frustration (knowing when activity will occur) • Increases successful use of functional language • Retrieval cues for recall of conventional communication • Maintains attention to task at hand • Marks place for task at hand • Decreases reliance on verbal prompts

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Guidelines for Creating Visual Systems Visual Schedules • We all benefit from visual schedules • Teach, don’t test. • Time must be allocated to appropriately use • The goal is to make the student an independent user of visual supports and to know when they need them. schedule • Keep it as simple as possible-more complex is not necessarily betterFocus on one sequence, • Be persistent, change is not easy task or communicative situation. You want to get it as right as you can the first time. • Teach, don’t test. Using a schedule will not happen • A system that is easily individualized and easily changeable is best. automatically. • Think about the portability of your system • High tech is not necessarily better. Always start with low tech and, if you go high tech, always • Not “Where are you supposed to be? Where are have a low tech backup system. we going next?” Instead “Look at your schedule. • Timers are your friends. In three minutes you need to be in lunch” Check your schedule, it is time for art.”

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13 Visual Sequences Rule Cards

• Mini-schedules • Many students with ASD like rules • Helps students complete tasks • They often have difficulty knowing when to apply rules • Keeps them attending to task • Subtlety and shades of gray in rules are not a strength • Marks place within a task (understatement) • Can be made on the spot • Simple rule cards often transform situations • Make sure child can do components of the task • Rule cards reduce verbal prompting

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Physical and Visual Structure of the Changing your Environment Environment • Different colored carpet • Your classroom environment should talk to the student; they should • Carpet squares and other markers on floor know what is and is not expected in certain areas. • • Separate carrel for student Visual organization will help child understand transitions and schedules • Partitions, bookshelves, file cabinets • Match symbols around class with symbols on the child’s schedule • Reduce visual clutter and distractions • Use sheets to cover things over • Organize materials in well marked system

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Project AIM: Autism Intervention Meta-analysis for Autism Intervention Meta-Analysis for Studies of Young Children Studies of Young Children by Sandbank, Micheal, et al. • Behavioral: Discrete trial, Verbal Behavior, Lovaas model • Psychological bulletin, 01/2020, Volume 146, Issue 1 • Developmental: Floortime, Hanen models and Responsive Teaching • Goal of study gather and synthesize all available studies of • NDBI: Incidental Teaching, Early Start Denver Model, SCERTS, Pivot interventions targeting outcomes below 8 years of age. Response Treatment • From 12,933; 150 studies met criteria representing 6240 participants • Looked at randomized control trial designs, looked at possible (1970-present) (no single subject designs) selective reporting, parent report, other bias. • Looked at Behavioral (ABA), developmental, NDBI, TEACCH, Sensory • Proximal vs. distal. Outcomes measured independent of therapy. based, Technology based, animal based.

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14 Autism Intervention Meta-Analysis for Studies of Results of Meta-Analysis Young Children • When limited to studies with randomized controlled “(ABA) Clinicians are encouraged to expand their trial designs, evidence of positive summary effects knowledge and skills to include naturalistic existed only for Developmental and NDBI intervention approaches that center on the principles of early types. childhood development.” • Researchers looked at proximal/distal and context boundedness of outcomes. Has skill generalized or only in specific context?

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Bottom Line Final Thoughts • Children with autism are children. • • Children develop in a predictable sequence. The rate of development Childhood only happens once. Don’t let your child get between domains might be different and uneven. robbed of their childhood because of a diagnosis. • Children learn best with developmentally appropriate stimuli in • Look for therapies that accept the child, find the child, and naturalistic, interactive, social environments. promote enjoyment, language, social competence, joint • Children learn best with safe, trusted, respectful, adults and peers. attention, spontaneous social interactions and where the • Children with autism have many neurological and cognitive challenges skills are generalizable, and the reinforcements are the that interfere with learning social skills, language, emotional interaction, the engagement and the success of learning. regulation, and adaptive behaviors. • Happy children, learn. • Our job is to understand, help the child understand, work through, compensate for, adapt to, and find the best in those challenges.

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References • Naturalistic Developmental Behavioral Interventions: Empirically Validated Treatments for Autism Some Interesting Links Spectrum Disorder. Laura Schreibman, Geraldine Dawson, Aubyn C. Stahmer, Rebecca Landa, Sally J. Rogers, Gail G. McGee, Connie Kasari, Brooke Ingersoll, Ann P. Kaiser, Yvonne Bruinsma, Erin McNerney, Amy Wetherby, Alycia Halladay. J Autism Dev Disord (2015) 45:2411–2428 • Project AIM: Autism intervention meta-analysis for studies of young children by Sandbank, • https://www.helpguide.org/harvard/autism-behavior-problems.htm Micheal; Bottema-Beutel, Kristen; Crowley, Shannon; Cassidy, Margaret; Dunham, Kacie; Feldman, Article on behavior Jacob I; Crank, Jenna; Albarran, Susanne A; Raj, Sweeya; Mahbub, Prachy; Woynaroski, Tiffany G. Psychological bulletin, 01/2020, Volume 146, Issue 1 • https://www.washingtonpost.com/lifestyle/2020/03/03/you-dont- • Cluster Randomized Trial of the Classroom SCERTS Intervention for Elementary Students with Autism Spectrum Disorder. Lindee Morgan, Jessica L. Hooker, Nicole Sparapani, Vanessa P. look-autistic-reality-high-functioning-autism/ WP article on HFA Reinhardt, Chris Schatschneider, and Amy M. Wetherby. J Consult Clin Psychol. 2018 Jul; 86(7): 631–644. • https://www.youtube.com/watch?v=T1HQKB2txgY&t=259s Ted Talk; • Using ESDM 12 hours per week in children with autism spectrum disorder: feasibility and results of an observational study. Geoffray MM, Denis A, Mengarelli F, Peter C, Gallifet N, Beaujeard V, Adult with Autism Grosmaitre CJ, Malo V, Grisi S, Georgieff N, Magnificat S, Touzet S.Psychiatr Danub. 2019 Sep;31(3):333-339 • Love on the Spectrum; Netflix series • A Multisite Randomized Controlled Two-Phase Trial of the Early Start Denver Model Compared to Treatment as Usual. Rogers SJ, Estes A, Lord C, Munson J, Rocha M, Winter J, Greenson J, Colombi • https://www.youtube.com/watch?v=OrQ0LfqxABM Chomsky talking C, Dawson G, Vismara LA, Sugar CA, Hellemann G, Whelan F, Talbott M.J Am Acad Child Adolesc Psychiatry. 2019 Sep; 58(9):853-865 about behaviorism

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