Post on 15-Feb-2019
Adult Core Competencies Curriculum:
Teaching Skills to Adults with Autism
and Severe Behavioral Challenges
John M. Guercio, Ph.D., BCBA-D, CBIST, LBA
Clinical Director-Beh
Licensed Behavior Analyst
Benchmark Human Services
St. Louis, Missouri 63141
jguercio@Benchmarkhs.com
The Numbers
• 5.5 million adults over the age of 20 with ASD.
• 1.3 million kids and adolescents (ages of 3-19). (Nightingale, 2012)
• Fewer than half of the adults are employed.
• Less than half live in a fully independent environment. (Gerhardt, 2009)
• They present with complex clinical needs.
• An average of 3 psychiatric diagnosis. (Buck et. Al., 2014)
• Recent surveys found that 75% of this population had an anxiety disorder diagnosis.
• Another 75% reported a depression
diagnosis.
Service Projections
• Fewer services available as adults.
• The “service cliff” plays a large role.
• Social skills raining and medication management are the biggest
“missing services.”
• Our service system is being flooded and it may not be prepared.
• The waiver systems statewide are primarily equipped to treat
people with ID or MI diagnosis.
• In 2010, 40 states had 428,571 people on waitlists for 149 waivers.
• Average wait time of 21 months. (Turcotte, Mathew, Shea, &
Brusilovskiy, 2016).
More Facts
• Early improvements in autism behavioral phenotype slow or stop after high school (Taylor & Seltzer, 2010).
• No formal mandates for services after high school. (Shattuck, et. Al.
2011).
• A novel and distinct set of services are required.
• The literature mentions career/vocational, speech language services.
• What about behavioral supports?
• We are training a generation of
behavior analysts that primarily
treat children.
Origins: The Lovaas Studies
• Conducted at UCLA over the course of many years.
• Initial outcome data reported in 1987.
• Kanner (1943) first identified autism as a disorder.
• He defined it as:
Lack of social interaction prior to 30 months of age.
Slow/no language development.
Ritualistic /obsessional behaviors.
Potential for “normal” intelligence.
Assessment Process
8 primary measures from parent interviews:
1. Verbal behavior
2. Toy Play
3. Emotional attachment
4. Peer play
5. Self-stimulatory behavior
6. Tantrums
7. Toilet training
8. Eye contact
Powerful Results
0
5
10
15
20
25
30
35
40
45
50
Treatment Controls
% "
no
rma
l" f
un
ctio
nin
g
Groups
"Normal" Intellectual and Educational Functioning
Primary Differences
• Aggression and its correlates.
• The use of aversives.
• Educational and social skills being the primary dependent
variables.
Some Numbers
Age Group Comparisons
Vocational Options
Contact with Law Enforcement
A Case Example
• Children’s Hospital for over 8 months from his academic setting due to a
series of violent behavioral issues that posed significant safety risks.
• Had been living with his mother and being transported to the program via a
cab service on a regular basis.
• Aggression ranged from breaking light bulbs in the home, burning the
comforter on his brother’s bed, cutting up his mother’s clothing and some
live wires in the home, urinating in inappropriate places, and frequent
elopement.
• 6’4” and being over 240 pounds, he has required up to 6 staff to keep him
safe at times.
• Mom almost died from a choke hold that he placed on her.
Approaches to Transitions
Autism
•Pre-instruction recommended.
•Visual displays/Use of video.
•Environmental labeling.
•Structure.
ABI/DD
•Spontaneous presentation.
•Sabotage.
•Allow no time for perseveration.
•Decrease SIB
Transition Efforts
Hospital
•Food delivered on a schedule.
•No food present in room.
•Periodic walks.
•Devoid of peers.
•Lack of behavioral expertise.
ISL
•Free access to food.
•Vehicle transport
•Peer interaction.
•RBT and BCBA staff.
•Systematic Desensitization.
•Multiple trips.
Manipulable Schedule
Quick Interaction Rings
Tolerance for Delays
Tacting Emotional States
Building Progressive Delays
Building a Voice
Behavioral Progress
Implications
• ABA with adults = ABA w/ kids.
• Expertise in crisis management.
• Positive interaction training/protocols.
• Functional communication strategies.
• Staff training.
Background on the ASSET• The ASSET was developed based upon the School-
Wide Evaluation Tool (SET) that is used to provide behavioral supports in school systems. Research based on the SET is listed below:
• Horner, R.H., Todd, A. W., Lewis-Palmer, T., Irvin, L. K., Sugai, G., & Boland, J.B. (2004). The
• School-Wide Evaluation Tool (SET): A Research Instrument for Assessing School-Wide
• Positive Behavior Support. Journal of Positive Behavioral Interventions. Vol 6. (1). pp. 3-12.
• For an abstract of this paper, or to purchase its full version, go to http://www.education.ucsb.edu/autism/jpbi-abstracts-volume_6/abstracts_v6n1w2004.html.
Agency Systems Support Evaluation Tool (ASSET)
Implementation Manual
• Assessment tool used by The Department of
Mental Health.
• Based in Positive Behavioral Supports.
• Goals:
• To determine the extent to which sites are already using
agency-wide positive behavior supports (AW-PBS),
• To determine if training and technical assistance efforts result
in change when using AW-PBS and
• To determine if use of AW-PBS procedures is related to
valued change in the safety, social culture, and violent
behavior in sites.
What is a Behavioral Technician?
• http://www.bacb.com/Downloadfiles/RB
T/RBT_Task_List.pdf
Data Based Decision Making
Evolution of a Form• The initial forms were separate.
Transportation Tolerance
Data Based Outcomes
A Detailed Forward Chaining
Procedure
Ricky’s Data
Fulton State Hospital
• 40 year old male.
• 20+ years of forensic placement.
• No community access.
• No telephones.
• Mattress on concrete floor.
• No other peers.
Joe’s Story
• Sporadic access to grounds.
• Staff used boxing pads on all outings on
grounds.
• Foods could not
• “touch.”
Joe’s Story
Fading Protocol
Community Tolerance Data
Aggressive Behavior
0
1
2
3
4
5
0
20
40
60
80
100
120
140
160
1 3 5 7 9 11 13 15 17 19 21 23
# o
f in
sta
nce
s o
f a
gg
ress
ion
min
ute
s in
th
e co
mm
un
ity
Sessions
Instances of aggression
/ /
Present
Minutes in the
community
Aggressive
Behavior
Policy
Community Trips
0
1
2
3
4
5
0
20
40
60
80
100
120
140
1 3 5 7 9 11 13 15 17 19 21 23
Esc
ort
s
Min
ute
s
Sessions
Minutes Spent in Community
Begin Reinforcer
Dr.'s Appointment
/ /
Present
Joe SIB
Community
Access Started
0
1
2
3
4
5
6
7
8
9
10
11/3
/20
14
1/3
/20
15
3/3
/20
15
5/3
/20
15
7/3
/20
15
9/3
/20
15
11/3
/20
15
1/3
/20
16
3/3
/20
16
5/3
/20
16
7/3
/20
16
9/3
/20
16
11/3
/20
16
1/3
/20
17
3/3
/20
17
5/3
/20
17
7/3
/20
17
9/3
/20
17
11/3
/20
17
1/3
/20
18
# o
f re
po
rted
iss
ues
Weeks
Self-Injurious Behavior
Mindfulness in Autism
Avoidance Assessment
Steps Completed
Outcomes
Development of a Curriculum
• Comprehensive Risk Assessment (Overt Aggression Scale, Yudofsky, 1986).
Assessment
• OAS informed functional behavioral
assessment.
• Institutional visits/evaluations.
• Detailed phone interviews with caregivers.
• Systematic transition process.
• Gathering of forensic/legal information as
indicated.
The Curriculum
The Curriculum
Measures of Well Being
THANK YOU