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Disclosure
• Dr. Hewitt teaches, presents and publishes on Video Modeling and Social Skills autism spectrum disorders; she is a faculty member and administrator at Bowling Green Training for Students with ASD in the State University and has supervised graduate Schools and Beyond clinicians in the Speech & Hearing Clinic for 7th Annual NSSHLA Conference at Chico State clients with ASD. She has received compensation March 5, 2016 from NSSHLA Chico State as well as Lynne Hewitt Bowling Green State University reimbursement for travel expenses for giving this Bowling Green, OH presentation. She has no other financial or non- lhewitt@bgsu. edu financial disclosures to make.
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Agenda • 9-10 A.M. • Roots of s oc ial pragmatic impairments in ASD Understanding ASD – Neurological underpinnings – Cognitive consequences – Co-mo rb i d d i so rd e rs • 10-11 A.M. • Types of problems and considerations for assessment/bas elining – Sch o o l age ch i l d re n • A spectrum • Case example – Adolescents • Case example • – Adults Likelihood of multiple causes • Case example • 11-12 A.M. • Interventions and supports for social communication • Co-morbid conditions – Sch o o l age ch i l d re n • Case example – Adolescents • Case example • “autisms” not “autism” ? – Adults • Case example
• 1-2 P.M. • Visual approaches to learning and self-reg ulation – Why visual. Complex information processing in ASD. – Static approaches, visual schedules, etc. – Dynamic--vi d e o -based • Video modeling • Video self-mo d e l i n g • 2-3 P.M. • Evidence base for video modeling – So u rce s o f re ad y-mad e mat e ri al s • 3-4 P.M. • Creating your own video models . Hew i tt Ma rc h 2016 4 Hew i tt Ma rc h 2016 5 • Q & A
Diagnosing Autism in the U.S., Two core impairments needed for diagnosis of ASD DSM-V: (June 2013) – Diagnostic & Statistical Manual of Mental – 1. Persistent deficits in social communication Disorders, fifth edition. American Psychiatric and interaction Society. • Deficits in social-emotional reciprocity – Major changes from older editions • Helps bring clinical dx in line with current research • Deficits in non-verbal communicative behavior for • Helps bring consistency to diagnostic practice social interaction • Somewhat more in line with the International – Gestures, facial expression, gaze Classification of Diseases used by most countries • Deficits in developing, maintaining, understanding (ICD-10) relationships – Useful summary available here: • https://www.autismspeaks.org/what- autism/diagnosis/dsm-5-diagnostic-criteria
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DSM-V core impairments, cont Other considerations
• 2. Restricted, repetitive patterns of • Must result in functional limitations behavior • Must occur during early developmental period – Stereotyped or repetitive motor movements, use of objects, or speech • Should not be better explained by intellectual – Insistence on sameness, inflexible adherence to disability routines or ritualized patterns of verbal or non-verbal behavior – If intellectual disability suspected, must confirm – Highly restricted fixated interests, abnormal in intensity that social communication ability below or focus expectations for level of functioning – Hyper- or hypo-reactivty to sensory input, or unusual sensory interest
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Levels of severity used in DSM-5 Considerations in diagnosis
• Level 3 Requiring very substantial support • Individuals without restrictive/repetitive • Level 2 Requiring substantial support behaviors may fall under social pragmatic • Level 1 Requiring support communication disorder – NOTE: this dx falls within our scope of practice – Not widely used/well understood as yet See DSM-V ASD summary at: https://www.autismspeaks.org/what- autism/diagnosis/dsm-5-diagnostic-criteria
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Thought Experiment How we are used to thinking of
• Imagine you are invited to a party. the brain – You don’t know anyone – You are not sure what is going to happen or what is expected of guests – You are unsure when it begins and ends • You get up your courage and go anyway – The social expectations are completely confusing • You can’t figure out how to talk to people—wh o is o pen an d wh o is b usy – It’s really loud so it’s hard to hear and understand anything that is said – There is a disco light set up so it’s hard to see people’s faces – The temperature is uncomfortable, and it’s crowded – There is nothing you like to eat or drink – There are no activities you like to do – Some people get upset with you for not doing what’s expected – So you get upset --no one told you what was expected and no one is helping you find out • They think you should just know, but that is impossible.
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How we need to start thinking about Issues in studying the brain the brain
• Naïve localizationism
http://www.semel.u cla. ed u/ bdd an or exi a/r ese ar ch/ pr oje ct/ http://commons .wiki me dia .o rg/wi ki/ File: Net wor k_ re pr e visual-functional- co nn ectivi ty sentation_of_b rai n_c on ne ctivity. JPG
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Neurobiology of ASD Advances in neuroscience for ASD vASD is now well understood to be disorder • Widespread brain differences of neurobiology – The landscape of the brain is different everywhere vIncreased risk of seizures one looks vCo-morbidity with other disorders vADD, ADHD vAnxiety vDepression vObsessive-compulsive disorder vOther psychiatric disorders vE.g., Tourette syndrome
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What do we know about the Research on brain structures & brains of persons with autism? connectivity in ASD • https://www.youtube.com/watch?v=BdMmPXgTGhc § Obvious lesions not present – Slide minute 3:54 on structures that are anomalous in the brains of individuals with ASD. R. Muller § Adult brain size usually within average range § Poss. macrocephaly in childhood § Subtle abnormalities widespread throughout brain § Amygdala § Cerebellum § Frontal lobe
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Issues in studying the brain Recent breakthroughs
• Problem is not one system but connection § Pitfalls in applying between systems knowledge from acquired to – Brain as an emergent system developmental • Dendritic growth and pruning disorders • Adult brain structure arises from gene- § Development matters! environmental input interaction – Structural differences in brains raised in deprived § Sometimes lesions shed environments light • Plasticity § Phineas Gage
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One example of long-distance Quote from Courchesne & connectivity problems Pierce (2005) vCourchesne and colleagues Maldevelopment on this scale, therefore, very likely vMany papers showing cerebellar anomalies reflects substantial defects ranging from neuronal vWhat does cerebellum do? numbers to molecular function and local and long- vMotor planning, learning, execution distance connectivity. The recognition of this process vHow could that relate to features of autism? as ongoing and massive reminds that autism is indeed vLogically, seems that frontal lobe must be involved a disorder of the developing brain. In the developing vFindings brain, the neural structural and functional landscape is vAbnormal connections between frontal lobe and created where none existed before, and so when cerebellum aspects of this process go substantially awry, we should vAbnormal rate of brain growth in early life expect to see a differently detailed landscape vPrimarily attributable to frontal lobe (connectivity, molecular expression, etc.) and not vAbnormal structure of frontal lobe neurons simply a largely normal landscape with perhaps just
Hew i tt Ma rc h 2016 22 one or two specific features precisely and conveniently Hew i tt Ma rc h 2016 23 omitted or changed.
Minshew & Williams (2007)
• Review of research in neurobiology • Key issues – Polygenetic disorder
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Minshew & Williams, cont. Minshew & Williams
• Systems affected in autism • Problems with inhibition, excitation – Not focal (localized) – Reduced boundaries between minicolumns – “Distributed neural systems abnormality” • Gray and white matter both involved in • Head growth abnormalities ASD – Increase in white and grey matter – Gray matter: neuronal cell bodies • Not just neural connectivity issue – White matter: myelinated axons (and glial – Minicolumn abnormalities cells)
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Minshew & Williams, cont. Minshew & Williams, cont.
• Decreased interhemispheric connectivity • FMRI findings – Reduced size of corpus callosum – Atypical timing, patterns of activation • Abnormal intrahemispheric connectivity • Language tasks • Working memory • Problem solving • Social Cognition
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Minshew & Williams, cont. Recent work in neuroimaging
• Sensory differences • Eigsti et al. (2016) investigated language – New brain findings indicate sensory processing using FMRI, in 3 groups: processing differences core to ASD – Optimal Outcome children and adults with ASD (OO) • “…autism had a far broader impact on the brain – High functioning autism (HFA) than was originally conceptualized.” (p. 949) – Typical peers (TD) • Findings: – OO and HFA showed similar patterns of processing – OO also showed more effortful processing than HFA
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Eigsti et al., cont. Caution on neuroscience
• Implications: “It should be kept in mind that despite the rapid technical advances in the field, MRI techniques remain limited to a level – Individuals with ASD use different strategies to of spatial and temporal resolution too coarse to visualize the process language synaptic or neuronal-level abnormalities that may be core features of disorders such as ASD. If this is the level from which • Even –and especially!--when apparently heterogeneity arises, neuroimaging may ultimately not be the indistinguishable from NT peers best tool for parsing these differences.” • Reference: Lenroot, R. K., & Yeung , P. K. (2013). Heterogeneity within Eigsti, I -M, Stevens, M., Schultz, R., Barton, M., Kelley, E., Naigles, L . , autism spectrum disorders: what have we learned from Orinstein, A. , Troyb, E., and Fein, D. (2016). Language comprehension and neuroimaging studies?. Frontiers in Human Neuroscience, 7, brain function in individuals with an optimal outcome from autism. 733. Neuroimage: Clinical, 10, 182-191.
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“The brains of humans are therefore meant to make meaning out of their Putting it all together surrounding environment. Unfortunately, in certain conditions, like • Social communication and social cognition autism, this capacity for contrast require appears diminished.” – Rapid decision-making Available at: • In complex environments http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384 515/ – Facial processing abilities, recognizing emotions, etc. – Language – Ability to filter out irrelevant information Casanova, M. F. (2010). Cortical organization: a – description and interpretation of anatomical findings Ability to hold (at least) two separate views at once: based on systems theory. Translational Neuroscience, • Own view 1(1), 62–71. http://doi.org/10. 2478/v10134-010- • Communicative partner’s view 0002-2
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Cognitive issues Other co-morbidities
• Theory of mind • Depression • Executive functioning • Anxiety • Impairment in central coherence • Obsessive-compulsive disorder • Attention deficit disorder • Bipolar disorder • Intellectual disabilities • Learning disabilities
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Other factors Sensory issues
• Sleep problems • Part of core symptomatology – https://www.disabilityscoop.com/2016/02/18/aut – Hyper-responsiveness ism-behavior-poor-sleep/21930/ – Hypo-responsiveness • Other co-morbid physical problems – May both be present in same individual – Food aversions, intolerances – Relate to ASD symptom severity, social pragmatic – http://www.sciencedirect.com/science/article/pii/ difficulties • Glod, M. , Riby, D . M. , Honey , E. , & Rodgers, J. (2015). Psy c hologic al S0882596313000961 Correlates of Sensory Processing Patterns in Individuals with Autism – Increased rates of seizure disorders Spectrum Disorder: A Systematic Review. Review Journal of Autism and Developmental Disorders, 2(2), 199-221.
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Our students Advantages to Informal Assessment • What is the world like for them? • Clinician determines what to measure, based • What would an optimal environment be? on concerns and expertise • Is a typical classroom a good setting for • Able to collect data about natural behaviors learners with ASD? and real-world functioning • Can use data collected as baselines for intervention goals
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Limitations of Formal Testing for Language & Disadvantages to Informal Assessment Communication in ASD • Many tests’ norming populations do not include • If artificial cut-off scores required to access individuals w/ASD – E.g., PPVT-4 attempted full range sampling reflecting services, cannot obtain from informal populations norms--it has exactly 4 participants between ages measures of 2 and 18 with ASD in its norming sample • Areas of language and communication with most • Need more expertise to interpret significant weaknesses may lack formal tests – Gestural communication – Knowledge of typical development – Prelinguistic and minimally linguistic communicative development • Norms lacking for pragmatics, unclear what metrics – Pragmatics – E.g., how to quantify “tactful communicator”? – Language to support success in the classroom • San th an am, S. & Hewitt, L. (in press). Evidence-based assessment and au t ism spectrum disorders: A scoping review . Evid en ce-Based Communication Assessment and • May be more time-consuming In terven tio n .
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Formal Tests Relevant to Social Suggestions for formal tests, cont. Communicative Assessment in ASD • Communication and Symbolic Behavior Scales Developmental Profile™ (CSBS DP™, Wetherby & Prizant) nd • Early development screener • Social Responsiveness Scale, 2 Ed. • Macarthur-Bates Communicative Development Inventories – Validated for ASD; good for toddlers through preschool • Test of Problem-Solving (TOPS) – Parent-administered checklist – Elementary TOPS 3 • Children’s Communication Checklist (CCC) • PPVT – Adolescent TOPS 2 – Advantages: simple format; no need for verbal expression; well- normed; can reveal unsuspected competence • Functional Assessment of Verbal Reasoning – Disadvantages: limited information gleaned; no guidance for intervention and Executive Strategies (FAVRES) • CASL subtests – Idiomatic language; Pragmatic judgment; Inference; Meaning from • Test of Language Competence, Inferencing context subscale
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Social Communication: approaches to Best practices in assessment assessment using informal protocols • Assessing higher functioning individuals, especially adolescents and adults, can prove challenging • Tak e a multi-pronged approach • Importance of communication sampling • Documentation of barriers to success in regular curriculum – Common core and state standards • Consider use of caregiver report instruments – Also hidden curriculum • Double interview – Available in W inner, M. (2007). Thinking about you, thinking about me: Teaching perspective taking and social thinking to persons with social cognitive learning challenges. (2nd ed.). San • Structured observations in critical contexts Jose, CA: Think Social Publishing. • Peer conflict resolution task. – Nippold, M.A. (2014). Language sampling with Adolescents, 2nd Ed. San Diego, CA: Plural • Interview person, if old enough Publishing • “Big picture” narrative coding – Barnes, J., & Baron-Cohen, S. (2012). The big picture: Storytelling ability in adults with autism spectrum conditions. Journal of Autism & Developmental Disorders, 42(8), 1557-1565. doi:10.1007/ s 10803-011-1388-5. • Narratives of personal experience – Rollins, P. R. (2014). Narrative skills in young adults with high-functioning autism spectrum dis orders. Communication Disorders Quarterly, 36(1), 21-28. doi:10.1177/1525740114520962 – Suggestions for college-going students/transition planning • Hewitt, L. (2015). Assessment considerations for college students with autism spectrum disorders. Topics in Language Disorders, 34:4, 313-328.
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EBP for busy clinicians: Suggested “quick & EBP: Clinical decision-making dirty”strategies
– National Stan d ard s P ro ject • Single most important aspect of effective http://www.nationalautismcenter.org/about/national.php – Google Sch o lar practice • Of ten can n o t get full text articles – ASHA website • Pathways to decision-making: • All ASHA journals free full-text on-line – Set up your account and pas s word – What you learned in school • ASHA Practice Portal http://www.asha.org/practice-portal/ • Also try – Your previous experience/beliefs – Sp ecial interest websites: many free resources – • ASA What your colleagues do/suggest • Apraxia-kid s.org – What is required/feasible in your work setting • To get a hold of information, maybe articles – Contact expert in academia – What families want • Helps if they are in your local area – Tr y e-mailing author of article you are interested in – Scientific evidence • Join Special Interest Group of ASHA – ASHA Community http:/ / community.as ha.org/ Dis cus s ions / Dig es tVi ewe r/ ?G rou pId =265&U s e rKey =e4f 77c70 - 733c-422e-8d56-760f5 133 bfea&sK ey=05 B2E DEEF 2D 04E 9A B027 Hew i tt Ma rc h 2016 48 Hew i tt Ma rc h 2016 49
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Best Practices in Intervention for Social Fundamentals in Intervention for ASD Communication Impairments in ASD • Grounded in best contemporary science • Level 3 individuals • Appropriate to ASD profile – Early intervention has clear benefits in averting – As neuroscience improves, interventions more social deficits intentionally designed—more to go on to decide what • EIBI to do • Maybe have more impact • Joint attention intervention • Early intervention now shown to benefit adaptive • Early Start Denver Model functioning, including social functioning • Gains possible at any age – Though dearth of research in older adults
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Take-away message from infant eye gaze study • Fundamental cause of ASD may be “paying attention to the wrong stuff” – That is, neglect of social input and emphasis on object input skews brain development – Fail to develop fundamental structures needed to process complex social info • Emergent networks responsible for social knowledge • Is there a potential window for diverting development back onto the right course? • Is 18 months too late?
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What interventions might target eye Interventions with supporting gaze? evidence • Early intervention approaches • In infancy? Unknown as yet – Early Intensive Behavioral Intervention – http://www.lovaas.com/ • Toddlers/preschoolers? – Pivotal response treatment – http://education.ucsb.edu/autism/pr t .ht ml – Naturalistic/social communication/focused – Enhanced Milieu Teaching stimulation types – http://kc.vanderbilt.edu/kidtalk/files/presentations/Kaiser_AUCD%20Webinar_2_22_11.pdf – Early Start Denver Model – Behavioral interventions – http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/ – Developmental Individualized Relationship-based (D.I.R. Floortime) – Technol og y /V i deos? – http://www.icdl.com/dirFloortime/overview/ – SCERTS model • Older children and adults – http://www.scerts.com/ – Is it too late? – Picture Exchange Communication System – http://www.pecsusa.com/ – If not, – HanenMore than Words – http://www.hanen.org/Home.aspx • Metacognitive approaches – JASP/ER: Joint attention, Structured Play, Emotion Regulation – http://www.ncbi.nlm.nih.gov/pubmed/229 65 29 8 Hew i tt Ma rc h 2016 54 – http://www.slideshare.net/autismsciencefd/connieHew i tt Ma rc h 2016 -kasari 55
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Joint attention intervention Early Start Denver Model
• Kasari et al. (2007) • Behavioral and naturalistic combination – Theory: social engagement needed for language development to progress normally • Developmental focus – Background: numerous studies show deficit in joint • Parent training attention in children with ASD – Joint attention is foundation of social engagement, so • Relationship-based increasing it should remediate and/or prevent some of the – Fostering social-cognitive, emotional, and social and language impairments in ASD communication development in everyday home – Intervention trains parents to engage children in play- environment based joint attention interactions • (some similarity to Floortime, SCERTS) – Dawson et al. (2010) – RCT showed gains in IQ, – Finding: increased joint attention AND increased adaptive behavior, & autism diagnosis at follow-up vocabulary (compared to treatment as usual)
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Issues in intervention for ASD past Issues in intervention for ASD past early years early years, cont. • Neurobiological • Families/school environments also develop – The longer a system has been developing, the patterns of responding, expectations harder it is to create system-wide change • Later language needs tap into weakest areas • Behavioral problems become entrenched – Social-emotional reciprocity • Problem-solving style refines itself – Inferencing – Co-morbid disorders may become more acute in later years – Executive functioning – – Adolescent changes can complicate matters Cognitive flexibility, creativity
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Intervention approaches for school Approaches to Improving Social age children with ASD Communication in School Age Children
• Theoretical bases y include video modeling – Behavioral • Metacognitive practice – Uses social skills drills, but supports with discussion to assist in raising • Claims of the potential for massive, system-wide change no longer awareness pertain as in EIBI • For higher functioning, older individuals • Behaviorists use these techniques with all ages, but EIBI targets early devel. – Winner’s social thinking approach falls here » Thinking about You, Thinking about Me – Naturalistic » www. Socialthinking. com • Challenge to identify motivating natural contexts and get students to – Social stories engage • attempt to raise metacognitive awareness of social situations • Unclear if similar results can be expected from child-centered approach as in younger ages – Social skills curricula • Many materials exist – Metacognitive – Games • Typical educational approach – Wo r kb o o ks – ID skill – So n gs – Explain skill – Practice skill • Classic problems of generalization, maintenance, cognitive readinessHew i tt Ma rc h 2016 60 Hew i tt Ma rc h 2016 61
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Approaches to Improving Social Communication Meta-cognitive approaches, cont. in School Age Children, cont. • Discussing problem objectively • Modification of environment • Autism Spectrum Quotient Test http://www. wired. com/wir ed/arc hive /9. 12/aqtest.html – AAC • Jackson (2002) “Freaks, Geeks, and Asperger Syndrome” – Visual schedules and other environmental cues • Myles, Trautman, & Schelvan (2004) – • Recent research applying cognitive behavioral therapy to ASD: Sensory diet more systematic and sophisticated use of metacognitive – Training of families, educational personnel, approach peers • Evidence-based practice in psychology; SLP’s not trained – Though some implementation with fluency disorders – Training at classroom or small group level – Evidence that CBT assists with anxiety, including social –Communication Lab (Dodge, 1998) anxiety –Jarvis Clutch, Social Spy (Levine, 2001) • Sung et al. (2011); White et al. (2010); White et al. (2013); Wood et al. (2009) »(also a metacognitive approach)
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Critical Need for Social Communication: Social Communication in ASD: Challenges Outcomes for Adults with ASD • Problem • Low rates of educational and vocational – Social skills, pragmatic language impairments are attainment even in cognitively able adults hallmarks of autism spectrum disorders with ASD – Insufficient controlled research on intervention techniques – Nevill & White (2011) • E.g., Social Thinking very popular, but 2015 NSP report – Levy & Perry (2011) excluded it as an EBP – Santhanam & Hewitt (2013) • Interviewed 8 young adults with ASD, found almost all saw limited benefit from or need for intervention, yet all articulated frustration with social and vocational success
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Adults with ASD: Underserved and Underemployed Quality of Life and ASD – Shattuck et al. (2011), in national survey, found low rates • Survey in Japan found lower self-reported quality of service usage post-high school (ages 19-23) of life for adults with high-functioning ASD than • 74% had SLP services in high school; only 9% did post high school general population • Use of all support services dropped substantially – Kamio, Inada & Koyama (2012) – Shattuck et al. (2012), in national survey, found over 50% of young adults with ASD were not employed or in school • Howlin et al. (2013) conducted standardized • 12.1% had attended college survey of 60 adults with ASD with at least average “Youth with an ASD had the lowest rates of participation IQ – in employment and the highest rates of no participation Only 10 rated as “good or very good” outcome compared with youth in other disability categories” p. – 60% rated as “poor or very poor” outcome 1042 • Measures focused on mental health, employment, independent living, social relations
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Legal Changes from Secondary to Post- Potential Reasons for Poor Outcomes Secondary • Co-morbid psychiatric disorders such as anxiety & depression; history of peer rejection • Shtayermman (2007) • IDEA for K-12 • White, Ollendick, & Bray (2011) • Undiagnosed or insufficiently managed learning – Free and appropriate public education disabilities and/or language impairments • ADA for work and college • Lack of appropriate early intervention • Late start – Reasonable accommodations • Lack of consistency, eclecticism – Equal access • Lack of intensity • For high-functioni ng individuals, talents and many – no modification to curriculum or performance strengths may mask significant difficulties expectations • concept of leveling the playing field
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How SLP’s can help improve Aspects of ASD Supporting College outcomes Success • Supports and interventions we offer target key risk areas – Communication • May have strong interest in subject of study • Oral an d w ritten – Social knowledge, social reasoning, social functioning • Relevant special talents – Linguistically and academically-related higher-order cognition • Average to superior intellectual ability • Self -management • Planning – writing, drawing, mathematics • Task analysis and problem-solving • Strategies for academic success • Committed to following rules • May enjoy reading, intellectual pursuit – Not as distracted by social life…
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Aspects of ASD not supporting academic ASD and the post-secondary environment success • Social • College expectations – social thinking, social communication – Independence • Samp le ab ilities: can navigate web to locate syllabi; can access e-mail for letter of – need for own space acco mmo d at io n s, p r in t , an d sh ar e w it h professor; can manage a planner or • Cognitive calendar – Problem-solving, higher order planning, decision-making – Executive functioning deficits • Sample abilities: can identify steps needed to complete assignment; can decide how • higher order planning much time to allocate to studying versus recreation; can identify need to contact professor and independently find out how to do so, then carry that out. • decision making – Multi-tasking • time management • Sample abilities: can listen to lecture, and view PowerPoint, while deciding what • organization notes to write down, and write them, while screening out background distracters – Sensory efficiency – Rigidity • Sample abilities: can manage to sleep and study in dorm, despite lighting and noise • difficulty adapting issues; can deal with smells and noises in cafeteria – Information processing – Spatial reasoning and way-finding • Sample abilities: can locate buildings on a campus map; can follow oral or written • difficulty dealing with complex input directions to locate new places and successfully navigate there independently • making rapid decisions in new environments – Social abilities • Emotional • Sample abilities: is aware of whether someone is open to interacting; knows what information to share, when; knows how to shift register – anxiety for different social groups – depression
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More on Social Abilities But if EBP is not clear for children….
• Social success: thinking about what others are thinking, all the time, and using that to make • Situation is much worse for adults decisions about your own actions – Basis of Winner (2007) approach. • Using this information, in real time, to present oneself positively, get social needs met – Requires micro-timing – Exhausting! • May be very under-developed in many 18 year olds on the spectrum
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Best practices for ASD: still relevant for adults Transition planning • Individualized • • Determining the true level of independence Breaking down complex information, teaching of the student new skills step-by-step – What supports are present? • Repetition – How do those contrast with what is available in • Reducing auditory input/increasing visual input college? • Realism is a must! • Making explicit and obvious what is inferred and – Craft goals that target areas where supports subtle are most likely to be absent in college • Expectation that developmental trajectory will • Self-management, higher order planning not be rapid
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Approaches to intervention for Communication goals for college
young adults with ASD • Professional communication: Goal areas for transition • Where are the needs? planning – Start with assessment • Makin g phone calls independently • E-mail • Basics: – Checking it – Interview with parents, case history – Courtes y/ res ponding – Interview w ith student – Interpreting nuances • Probing pragmatics » “she said ‘get it to me when you can’” • Of f ice h o u rs – Double interview (Winner, 2007) • • Executive functioning Campus services • Reading a syllabus – FAVRES • How to work in groups • Literacy/residual language impairments – “That kid is an idiot but I know not to tell him so” – Surprising number of students have difficulty with college level reading comprehension
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Using Winner’s Social Thinking Communication goals for Curriculum college, cont. • Core concepts • Social communication: Goal areas for transition planning – – Living in the dorm Teaching socially oriented problem-solving • Roommates ? – – Approaching people Step-by-step breakdown of how to understand what • How do you know who you can talk to? others are thinking so you can predict what they will • Hi g h tec h c orol l a ry : – Who can you text do » And how often… – Follow on social media – Quote from first year student with ASD – Conversation • Topics » “It’s impossible to know what anyone is thinking unless you – Appropriateness are a mind reader” » Er r o r s o f q u al i t y – Manipulation • Expected and unexpected behaviors » Er r o r s o f q u an t i t y • Partner-foc us ed ques tions • “Thinking with your eyes”—how to enter social situations – “Th e so ci al fake” – Reciprocity • Winner 2007a and b references in your handout
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Unresolved learning disabilities and/or Other stuff to think about missing skills • Way finding • Higher order reading comprehension – Many with ASD have difficulty with spatial reasoning; may be masked if they are used to supports • Note taking • Clothing choices – Clothing communicates…. • Study strategies • Vulnerabilities to exploitation – Goals for understanding when others are inappropriate • Understanding college level assignments • Student Code of Conduct may help • Video game addiction – “I don’t know where to start” • Time management – Using a planner – Tec h n o l o gy ai d s
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Managing co-morbid psychiatric Anxiety and depression problems • Individuals with ASD at high risk for other • Can destroy a student’s college career psychiatric problems – families must be prepared with a plan – If working with a psychiatrist/psychologist, what – Students need skills to identify problem and seek supports available? help – What is on campus? – Students with this profile might consider a 2 + 2 • Often campus services intended for short term approach, starting at a community college counseling – Can they take their medication independently? • And will they?
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Cognitive Behavioral Therapy Whose college career is it?
• Evidence-based practice for many • Student must have internal motivation psychological problems – College is a low-structured situation – Well-documented as effective for social anxiety in • Designed as transition to adulthood – No amount of emails, phone calls, texts and visits from ASD parents can create the internal drive in the student if it is • See Hewitt 2014 for a review lac king • Neurobiology revisited: – http://sig1perspectives.p ubs.a sha.org /art icle.aspx?ar ticleid =1 838333 – All college students can get exhausted and stressed – College students with ASD will often be more so » Plunged into stressful context ill-matched to their unique profiles • -àevery day can be a huge challenge.
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Modeling in ASD: Behavioral Modeling in ASD: Imitation treatments • Imitation abilities • – Lack of imitation is a red flag for ASD in toddlers Very large literature supports behavioral – But…superior imitation abilities seen in other realms interventions for ASD, especially EIBI • Echoed speech – Reichow, B. (2012). Overview of meta-analyses on early intensive behavioral • Savant abilities intervention for young c hildren with autism spec trum disorders. Journal of • “Hyper-imitation” Autism and Developmental Disorders, 42(4), 512-520. – Key componentsof this treatment include modeling – So is imitation impaired in ASD, or actually superior? • Task analysis – Sowden, S., Koehne, S., Catmur, C., Dz i obek , I. and Bird, G. (2016), Intact automatic imitation and typical • Repetition spatial compatibility in autism spectrum disorder: Challenging the Broken Mirror Theory. Autis m Res earch, 9: 292–300. doi: 10.1002/aur.1511 • Reward for correct imitation • Automatic imitation actually superior • Socially mediated imitative behaviors impaired – Not because imitation ability lacking, but because of difficulties with complex, social situations » Individuals with impaired theory of mind found to be “hyper-imitators” (Spengler, Bird, et al., 2010)
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Visual Supports in ASD Social Stories
• Gray (2000) • Many visual approaches – Simple sentences • Specific types of sentences – Picture Exchange Communication System – Pictures, if needed – Tailored to child – Social Stories – Specific guidelines: • List desired behaviors, not prohibited ones – Visual Teaching • Give choices • Use “sometimes”, “may”, etc. – Visual Schedules – Helps decrease rigidity • Plan to fade them over time • More resources from Carol Gray: http://www.thegraycenter.org/index.cfm
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More visual approaches Visual approaches, cont.
• Learning to read emotional cues • Schedules, Planners, Visual Organizers – Software games – Rationale • E.g., Mind Reading • http://autismcoach.com/Mind %20 Read ing. htm • Decreases anxiety by increasing knowledge of what to expect • Communicating about emotions • Incorporates language to go with situation – Visual communication notebooks – Especially if student can read • Decrease memory burdens on student • Limited evidence for any of these, despite popularity
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So, do any of the above work? Social Stories: Evidence lacking
• Evidence-based practice for ASD and pragmatics Case example: Social Stories (Gray, 2000) – We are not there yet Daneshvar (2006) Did not find social stories effective in teaching social behaviors to • Bellini, Peters, Benner & Hopf (2007) children wit h ASD – Metaanalysis of social skills training studies for ASD Scattone et al. (2006) Effective for 2 of 3 children in small study » Little to no effect Rust & Smith (2006) • More hopeful results found in below review: Review of studies to date found confounds Other interventions at same time preliminary low level evidence shows modest gains Different behaviors expected from caregivers for social skills group and individual training, as well Designs weak Generalization beyond duration of the study not investigated as peer modeling: Some withdrawal designs suggest behavior reverts when – Burgess, S., & Tu r kst r a, L.S. (2006). Social Skills Intervention for Adolescents story withdrawn with Autism Spectrum Disorders: A Review of the Experimental Evidence. EB P Briefs, 1(4), 1 -21.
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So, do social stories work? Visual teaching strategy
• Information is inconclusive • Important to incorporate them within a more comprehensive behavioral plan • Need to be well-integrated into child’s environment, individualized to their needs • Not clear how long-term the effects are
http://www. specialed. us/autism/printinst. htm
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Why Visual Visual vs. Auditory
• Not necessarily because vision in and of itself Visual Auditory better in ASD • Persists through time • Transitory – Some evidence suggests auditory issues: • Can be repeated exactly • For speech, exact repetition • Roth, D. A. E., Mu ch n ik, C., Sh ab tai, E., Hildesheimer, M., & Henkin, Y. ( 2 0 1 2 ) . • Can usually process only possible with recording Evidence for atypical auditory brainstem responses in young children with separate elements, if need • Cannot easily process suspected autism spectrum disorders. Developmental Medicine & Child Neurology, 54(1), 23-29. be separate components – However, nature of visual information inherently – E.g., examining details of different than auditory shape or position
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Visual Supports for ASD Modeling
• Visually enhanced environments • Providing intentionally planned input – E.g., work bins, footprints to show where to go, demonstrating some behavior Time Timers • Strict definition involves demonstration alone, • Written and/or graphic instructions or without instruction or feedback prompts – This is how it is used in the most naturalistic – E.g., Red/yellow/green lights language therapy approaches • Visual schedules/visual activity schedules – Modeling plus feedback used in more structured approaches
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Static vs. dynamic input Static vs. dynamic, cont.
• Visual schedules/visual activity schedules are • Problem: static – Imitation in ASD not impaired at basic level – Evidence-based practice for ASD – Problems arise with complex, especially complex • Knight, V., Sartin i, E., & Sp riggs, A. D. (2015). Evaluating visual activity schedules as evidence-based practice for individuals with autism spectrum social, activities disorders. Journal of Autism and Developmental Disorders, 45(1), 157-178. • Dynamic demonstration – Good for providing unchanging cues for expected – Live demonstrations have same problems as sequences of activities auditory input – Decrease need to auditory prompts and reminders • Transitory, hard to replicate exactly – Increase independence • Processing limitations of person with ASD may conflict with patience and exactness of person providing model
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Modeling: An Evidence-Based Practice Video Modeling Rationale for ASD – Many behaviors are learned though observation • National Standards Project (2015) identified of others in the world modeling and video modeling as evidence – Video allows one to focus in on desired behaviors based without outside distractors – http://www.nationalautismcenter.org/national- – Allows repeated, identical viewings to focus on standards-project/ specific details National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author.
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Video Modeling Support in the However… Literature: Recent Examples • Applying rigorous criteria for establishing an • Play and play-based social behaviors evidence-based practice, McCoy et al. (2016) – Boudreau & Harvey, 2013; Kourassanis, Jones, & Fienup, 2015; Sani- Bozkurt & Ozen, 2015 did NOT find video modeling for social skills to • Workplace supports have sufficient evidence – Burke et al., 2013; Kellems, 2010 • Social communication, social abilities – Issues: – Chen, Lee, & Lin, 2016; Hochhauser, Gal, & Weiss, 2015; Kabashi, • 2013; Mason et al., 2012; O’Handley, Radley, & Whipple, 2015; Ozerk Lack of rigorous participant description/diagnosis & Ozerk, 2015; Wilson, 2013a; Wilson 2013b • Failure to establish experimental control • Academic skills – Studies showed positive results, but were not – MacDonald et al., 2015; Yakubova, Hughes, & Hornberger, 2015 • Self-help, activities of daily living conducted in a sufficiently rigorous manner, per – McLay et al., 2015 procedures advocated by Reichow (2011): – Spriggs, Knight, & Sherrow, 2015;
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Video self modeling Video Modeling • Video modeling • Models created by skillful editing that purport to show the • Models created by others for client to watch client performing the target skill – Commercial materials – (Gelbar, Anderson, Mc Carthy , & Buggey, 2012) » E.g. http:/ / www.modelmekids.com/ – Some show “Don’ts” as well as “Do’s” – May confuse extremely literal children • Theory • Teach er /clin ician -created materials – Increased motivation and attention when model resembles self – Adult models – Provides supportive input of seeing oneself produce target – Peer models behavior • Materials taken from mass media or social media sites – TV, movies, YouTube – ‘I can do this because I already have’ » Some great colleagues share resources: • https :/ / jillkuz ma.wordpres s .com/ you tub e-vid eo-li nks-for-soci al-skills/ • • https :/ / www.pinteres t.com/ dow eras s ocia tes / video -modeling/ Hybrid approach • Create models, video client copying them, play video back, have client self critique, try again
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Creating your own videos: Technology Determining goals for video modeling Considerations • Smart phones, tablets, computers with built-in • For younger children, based on cameras—video is everywhere. – – Easy to take Functional impact – Easy to edit • Is behavior socially isolating/imposing a barrier to access to curriculum or other life contexts? – Easy to delete? • Degree of variation from the norm • Issues to consider: – Privacy: if you use your own smart phone, do you have • Is it potentially dangerous for the person? technical ability to delete a video so it is not recoverable? – E.g., lack of knowledge of appropriate topics may be nuisance in a 3rd grader, but harassment in a 10th grader • Make sure it is not synced to any cloud apps • Supposedly video deleted from iPad that you took on iPad is • Caregiver concern permanently gone if you did not back it up – https://discussions.apple.com/thread/3747602?tstart=0 – Frequency
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Determining goals for video modeling, Making videos cont. • For older children and adults, all on previous slide still • Short relevant, and in addition: • • Client’s perspective and needs Simple, with a clear scenario – E.g., Desire to change • Repetition • I want to communicate better with my co-workers. – Good basis to begin work • Client practice • I am not a smiley person—it’s artificial and I need to be myself. – Cannot target goal no matter how impactful for the client’s problem. – Video those, ask to compare – Note: Adolescents may not have readiness, which may be neurological; may need more executive function development to help with impulse control and taking the long view
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Privacy and security Technical considerations
• Permission to take video? • Lighting • Permission to keep video for reuse? • Background • On school/clinic equipment, is it securely • Audio quality stored? Could others access it? • Editing – iMovie not too hard to figure out • Use of avatars, other cutting edge tech – http://buggeyvsm.net/resources.html
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Groups Let’s try it out
• The cool factor – When is it too much fun to be practical? • Establish ground rules – List of rules and regs – Visual schedule for video modeling sessions – Consequences
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Contact Information
• Lynne Hewitt • [email protected] • 419-372-6031
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