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VideoModelingandSocialSkillsTrainingforStudentswithASDinthe

SchoolsandBeyond7th AnnualNSSHLAConferenceatChicoState

March5,2016LynneHewitt

BowlingGreenStateUniversityBowlingGreen,OHlhewitt@bgsu.edu

Disclosure

• Dr.Hewitt teaches, presentsandpublishesonautism spectrum disorders; she isa facultymember andadministrator atBowling GreenState University andhassupervised graduateclinicians in theSpeech &Hearing Clinic forclientswith ASD.Shehas received compensationfromNSSHLA ChicoState aswell asreimbursement for travel expenses forgiving thispresentation. Shehasnoother financial ornon-financial disclosures tomake.

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Agenda• 9-10A.M.• Roots ofsocialpragmaticimpairments inASD

– Neuro logical unde rp inn ings– Cogn itive conse que nce s– Co -morb id d iso rde rs

• 10-11A.M.• Typesofproblemsandconsiderations forassessment/baselining

– Schoo lage ch ild re n• Case e xamp le

– Ado le sce n ts• Case e xamp le

– Adu lts• Case e xamp le

• 11-12A.M.• Interventions andsupports forsocialcommunication

– Schoo lage ch ild re n• Case e xamp le

– Ado le sce n ts• Case e xamp le

– Adu lts• Case e xamp le

• 1-2P.M.• Visualapproachestolearningandself-regulation

– Why visual. Comp le x in fo rmation p roce ssing in ASD.– Static app roache s, visual sche du le s,e tc.– Dynamic--vide o -base d

• Vide o mode ling• Vide o se lf-mode ling

• 2-3P.M.• Evidencebaseforvideomodeling

– Source s o f re ady-made mate rials

• 3-4P.M.• Creatingyourownvideomodels .• Q&A HewittMarch2016 4

UnderstandingASD

• Aspectrum• Likelihood ofmultiple causes• Co-morbid conditions• “autisms” not“autism” ?

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DiagnosingAutismintheU.S.,DSM-V:(June 2013)

– Diagnostic & Statistical Manual of Mental Disorders, fifth edition. American Psychiatric Society.

– Major changes from older editions• Helps bring clinical dx in line with current research• Helps bring consistency to diagnostic practice• Somewhat more in line with the International

Classification of Diseases used by most countries (ICD-10)

– Useful summary available here:• https://www.autismspeaks.org/what-

autism/diagnosis/dsm-5-diagnostic-criteria

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Twocoreimpairments neededfordiagnosis ofASD

– 1. Persistent deficits in social communication and interaction• Deficits in social-emotional reciprocity• Deficits in non-verbal communicative behavior for

social interaction– Gestures, facial expression, gaze

• Deficits in developing, maintaining, understanding relationships

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DSM-Vcoreimpairments, cont

• 2. Restricted, repetitive patterns of behavior– Stereotyped or repetitive motor movements, use of

objects, or speech– Insistence on sameness, inflexible adherence to

routines or ritualized patterns of verbal or non-verbal behavior

– Highly restricted fixated interests, abnormal in intensity or focus

– Hyper- or hypo-reactivty to sensory input, or unusual sensory interest

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Otherconsiderations

• Mustresult infunctional limitations• Mustoccur during earlydevelopmental period• Should notbebetter explained byintellectualdisability– Ifintellectualdisabilitysuspected,mustconfirmthatsocialcommunicationabilitybelowexpectationsforleveloffunctioning

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LevelsofseverityusedinDSM-5

• Level3Requiring verysubstantial support• Level2Requiring substantial support• Level1Requiring support

SeeDSM-VASDsummary at:https://www.autismspeaks.org/what-

autism/diagnosis/dsm-5-diagnostic-criteria

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Considerations indiagnosis

• Individuals without restrictive/repetitivebehaviors mayfallunder socialpragmaticcommunication disorder– NOTE: thisdxfallswithinourscopeofpractice– Notwidelyused/wellunderstoodasyet

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ThoughtExperiment• Imagineyouare invited toaparty.

– Youdon’tknowanyone– Youarenotsurewhatisgoingtohappenorwhatisexpectedofguests– Youareunsurewhenitbeginsandends

• Yougetup yourcourageandgoanyway– Thesocialexpectationsarecompletelyconfusing

• Youcan’tf igureouthowtotalktopeople—whoisopenandwhoisbusy– It’sreallyloudso it’shardtohearandunderstandanythingthatis said– Thereisadiscolight setupso it’shardtoseepeople’sfaces– Thetemperatureisuncomfortable,andit’scrowded– Thereisnothingyouliketoeatordrink– Therearenoactivitiesyouliketodo– Somepeoplegetupsetwithyoufornotdoingwhat’sexpected– Soyougetupset--noonetoldyouwhatwasexpectedandnooneishelping

youfindout• Theythinkyoushouldjustknow,butthatisimpossible.

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Howweareusedtothinkingofthebrain

HewittMarch2016 13http:/ /www.biausa.org/ living-wit h-b rain -injury.htm

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Issues in studying the brain

• Naïve localizationism

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Howweneedtostartthinkingaboutthebrain

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http://www.semel.u cla. ed u/ bdd an or exi a/r ese ar ch/ pr oje ct/visual-functional- co nn ectivi ty

http://commons .wiki me dia .o rg/wi ki/ File: Net wor k_ re pr esentation_of_b rai n_c on ne ctivity. JPG

Neurobiology of ASDvASD is now well understood to be disorder

of neurobiologyvIncreased risk of seizuresvCo-morbidity with other disorders

vADD, ADHDvAnxietyvDepressionvObsessive-compulsive disordervOther psychiatric disorders

vE.g., Tourette syndrome

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Advancesinneuroscience forASD

• Widespread brain differences– The landscapeofthebrainisdifferenteverywhereonelooks

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What do we know about the brains of persons with autism?

§ Obvious lesions not present§ Adult brain size usually within average

range§ Poss. macrocephaly in childhood

§ Subtle abnormalities widespread throughout brain§ Amygdala§ Cerebellum§ Frontal lobe

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Research on brain structures & connectivity in ASD

• https://www.youtube.com/watch?v=BdMmPXgTGhc– Slide minute 3:54 on structures that are anomalous in the brains of

individuals with ASD. R. Muller

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Issues in studying the brain

§ Pitfallsinapplyingknowledge fromacquired todevelopmentaldisorders§ Developmentmatters!§ Sometimeslesionsshedlight§ PhineasGage

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Recent breakthroughs

• Problem is not one system but connection between systems– Brain as an emergent system

• Dendritic growth and pruning• Adult brain structure arises from gene-

environmental input interaction– Structural differences in brains raised in deprived

environments

• Plasticity

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One example of long-distance connectivity problems

vCourchesne and colleagues vMany papers showing cerebellar anomalies

vWhat does cerebellum do?vMotor planning, learning, execution

vHow could that relate to features of autism?vLogically, seems that frontal lobe must be involved

vFindingsvAbnormal connections between frontal lobe and

cerebellumvAbnormal rate of brain growth in early life

vPrimarily attributable to frontal lobevAbnormal structure of frontal lobe neurons

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Quote from Courchesne & Pierce (2005)

Maldevelopment onthisscale,therefore,verylikelyreflectssubstantialdefectsrangingfromneuronalnumberstomolecularfunctionandlocalandlong-distanceconnectivity.Therecognitionofthisprocessasongoingandmassiveremindsthatautismisindeedadisorderofthedeveloping brain.Inthedevelopingbrain,theneuralstructuralandfunctionallandscapeiscreatedwherenoneexistedbefore,andsowhenaspectsofthisprocessgosubstantiallyawry,weshouldexpecttoseeadifferentlydetailedlandscape(connectivity,molecularexpression,etc.)andnotsimplyalargelynormallandscapewithperhapsjustoneortwospecificfeaturespreciselyandconvenientlyomittedorchanged.

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Minshew & Williams (2007)

• Review of research in neurobiology• Key issues

– Polygenetic disorder

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Minshew & Williams, cont.

• Systems affected in autism – Not focal (localized)– “Distributed neural systems abnormality”

• Head growth abnormalities– Increase in white and grey matter

• Not just neural connectivity issue– Minicolumn abnormalities

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Minshew & Williams

• Problems with inhibition, excitation– Reduced boundaries between minicolumns

• Gray and white matter both involved in ASD– Gray matter: neuronal cell bodies– White matter: myelinated axons (and glial

cells)

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Minshew & Williams, cont.

• Decreased interhemispheric connectivity– Reduced size of corpus callosum

• Abnormal intrahemispheric connectivity

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Minshew & Williams, cont.

• FMRI findings– Atypical timing, patterns of activation

• Language tasks• Working memory• Problem solving• Social Cognition

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Minshew & Williams, cont.

• Sensory differences– New brain findings indicate sensory

processing differences core to ASD• “…autism had a far broader impact on the brain

than was originally conceptualized.” (p. 949)

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Recent work in neuroimaging

• Eigsti et al. (2016) investigated language processing using FMRI, in 3 groups: – Optimal Outcome children and adults with ASD (OO)

– High functioning autism (HFA)

– 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.

• Implications:– IndividualswithASDusedifferentstrategiestoprocesslanguage• Even–andespecially!--whenapparentlyindistinguishablefromNTpeers

•Reference:Eigsti, I-M,Stevens, M.,Schultz, R.,Barton, M.,Kelley, E.,Naigles, L.,Orinstein, A.,Troyb, E.,and Fein, D.(2016).Languagecomprehension andbrain function in individuals with anoptimal outcome fromautism.Neuroimage: Clinical, 10,182-191.

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Caution on neuroscience

“Itshouldbekeptinmindthatdespitetherapidtechnicaladvancesinthefield,MRItechniquesremainlimitedtoalevelofspatialandtemporalresolutiontoocoarsetovisualizethesynapticorneuronal-levelabnormalitiesthatmaybecorefeaturesofdisorderssuchasASD.Ifthisisthelevelfromwhichheterogeneityarises,neuroimagingmayultimatelynotbethebesttoolforparsingthesedifferences.”

Lenroot,R.K.,&Yeung,P.K.(2013).Heterogeneitywithinautismspectrumdisorders:whathavewelearnedfromneuroimagingstudies?.FrontiersinHumanNeuroscience,7,733.

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“Thebrainsofhumansarethereforemeanttomakemeaningoutoftheirsurroundingenvironment.Unfortunately,incertainconditions,likeautism,thiscapacityforcontrastappearsdiminished.”

Availableat:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384515/

Casanova,M.F.(2010).Corticalorganization:adescriptionandinterpretationofanatomicalfindingsbasedonsystemstheory.TranslationalNeuroscience,1(1),62–71.http://doi.org/10.2478/v10134-010-0002-2

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Puttingitalltogether

• Social communication andsocial cognitionrequire– Rapid decision-making

• Incomplexenvironments– Facialprocessing abilities,recognizing emotions, etc.– Language– Abilitytofilteroutirrelevantinformation– Abilitytohold(atleast) twoseparateviewsatonce:

• Ownview• Communicativepartner’sview

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Cognitive issues

• Theoryofmind• Executive functioning• Impairment incentral coherence• Attention deficit disorder• Intellectual disabilities• Learning disabilities

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Otherco-morbidities

• Depression• Anxiety• Obsessive-compulsive disorder• Bipolar disorder

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Otherfactors

• Sleepproblems– https://www.disabilityscoop.com/2016/02/18/autism-behavior-poor-sleep/21930/

• Other co-morbid physicalproblems– Foodaversions,intolerances– http://www.sciencedirect.com/science/article/pii/S0882596313000961

– Increasedratesofseizuredisorders

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Sensory issues

• Partofcore symptomatology– Hyper-responsiveness– Hypo-responsiveness– Maybothbepresentinsameindividual– Relate toASDsymptomseverity,socialpragmaticdifficulties

• Glod,M.,Riby,D.M.,Honey,E.,&Rodgers,J. (2015).PsychologicalCorrelatesofSensoryProcessingPatternsin IndividualswithAutismSpectrumDisorder:ASystematicReview.ReviewJournalofAutismandDevelopmentalDisorders,2(2),199-221.

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Ourstudents• Whatistheworld likeforthem?• Whatwould anoptimal environment be?• Isatypical classroom agoodsetting forlearners with ASD?

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AdvantagestoInformalAssessment

• Clinician determines whattomeasure, basedonconcerns andexpertise

• Abletocollect dataabout natural behaviorsandreal-world functioning

• Canusedatacollected asbaselines forintervention goals

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DisadvantagestoInformalAssessment

• Ifartificial cut-off scoresrequired toaccessservices, cannot obtain frominformalmeasures

• Needmore expertise tointerpret– Knowledgeoftypicaldevelopment

• Normslackingforpragmatics,unclearwhatmetrics– E.g.,how toquantify “tactful communicator”?

• Maybemore time-consuming

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LimitationsofFormalTesting forLanguage &Communication inASD

• Manytests’ norming populations do notincludeindividualsw/ASD– E.g.,PPVT-4attemptedfullrangesamplingreflectingpopulationsnorms--ithasexactly4participantsbetweenagesof2and18withASDinitsnormingsample

• Areasof languageand communication withmostsignificantweaknessesmaylackformal tests– Gestural communication– Prelinguistic andminimallylinguisticcommunicativedevelopment

– Pragmatics– Language tosupportsuccessintheclassroom

• Santhanam, S. & Hewitt, L. ( inpress) . Evidence-based assessment andautism spectrumdisorders: Ascoping review. Evidence-Based CommunicationAssessment andIntervention.

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FormalTestsRelevanttoSocialCommunicativeAssessmentinASD

• Communication and Symbolic Behavior Scales Developmental Profile™ (CSBS DP™, Wetherby & Prizant)• Early development screener

• Macarthur-Bates CommunicativeDevelopmentInventories– Validated forASD;good fortoddlers throughpreschool– Parent-administered checklist

• Children’sCommunicationChecklist(CCC)• PPVT

– Advantages: simple format;noneedforverbalexpression;well-normed;canrevealunsuspected competence

– Disadvantages:limited informationgleaned;noguidance forintervention

• CASLsubtests– Idiomaticlanguage;Pragmaticjudgment;Inference;Meaning from

context

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Suggestions forformaltests,cont.

• SocialResponsiveness Scale,2nd Ed.• TestofProblem-Solving (TOPS)

– ElementaryTOPS3– AdolescentTOPS2

• Functional AssessmentofVerbal ReasoningandExecutive Strategies(FAVRES)

• TestofLanguageCompetence, Inferencingsubscale

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SocialCommunication:approachestoassessmentusinginformalprotocols

• Assessing higher functioning individuals, especially adolescents andadults, canprovechallenging

• Importanceof communicationsampling• Documentationofbarrierstosuccessinregularcurriculum

– Common core ands tates tandards– Alsohidden curriculum

• Doubleinterview– AvailableinWinner, M.(2007). Thinkingabout you,thinking about me:Teachingperspective

takingand socialthinkingtopersons with socialcognitivelearningchallenges . (2nded.). SanJose,CA: ThinkSocialPublishing.

• Peerconf lictresolutiontask.– Nippold,M.A. (2014). Language samplingwithAdolescents ,2nd Ed.SanDiego,CA: Plural

Publishing• “Bigpicture”narrativecoding

– Barnes , J.,&Baron-Cohen, S.(2012). Thebigpicture: Storytelling ability inadults with autismspectrum conditions . Journal ofAutism &Developmental Disorders , 42(8), 1557-1565.doi:10.1007/s10803-011-1388-5.

• Narrativesof personalexperience– Rollins ,P. R.(2014). Narrative skills inyoungadults withhigh-functioning autismspectrum

disorders . Communication Disorders Quarterly, 36(1),21-28. doi:10.1177/1525740114520962

– Suggestionsforcollege-goingstudents/transitionplanning• Hewitt,L.(2015).Assessmentcons iderations forcollegestudents withautismspectrumdisorders .Topics in

LanguageDisorders ,34:4,313-328.

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Bestpracticesinassessment

• Takeamulti-pronged approach• Consider useofcaregiverreport instruments• Structured observations incritical contexts• Interview person, ifoldenough

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EBP:Clinicaldecision-making

• Singlemostimportant aspect ofeffectivepractice

• Pathwaystodecision-making:– Whatyoulearnedinschool– Yourpreviousexperience/beliefs– Whatyourcolleaguesdo/suggest– Whatisrequired/feasibleinyourworksetting– Whatfamilieswant– Scientificevidence

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EBPforbusyclinicians: Suggested“quick &dirty”strategies

– National StandardsProjecthttp://www.nationalautismcenter.org/about/national.php

– Google Scholar• Oftencannotgetfulltextarticles

– ASHA website• AllASHA journalsfreefull-texton- line

– Set upyour account and password• ASHAPracticePortalhttp://www.asha.org/practice-portal/

• Also try– Special interestwebsites:many free resources

• ASA• Apraxia-kids.org

• Togetaholdofinformation,maybearticles– Contactexpertinacademia

• Helps if theyare inyourlocalarea– Trye-mailing authorof articleyouareinterested in

• JoinSpecialInterestGroupofASHA– ASHA Community

http:/ /community.asha.org/ Discuss ions/Dig estVi ewe r/?Grou pId =265&Use rKey =e4f 77c70 -733c-422e-8d56-760f5 133 bfea&sK ey=05 B2E DEEF 2D04E 9A B027

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FundamentalsinInterventionforASD

• Grounded inbestcontemporary science• Appropriate toASDprofile

– Asneuroscience improves, interventionsmoreintentionallydesigned—more togoon todecidewhattodo

• Maybehavemoreimpact

• Early intervention nowshowntobenefitadaptivefunctioning, includingsocial functioning

• Gainspossibleatanyage– Though dearth ofresearch inolder adults

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BestPracticesinInterventionforSocialCommunicationImpairmentsinASD

• Level3individuals– Early interventionhasclearbenefitsinavertingsocialdeficits• EIBI• Jointattentionintervention• EarlyStartDenverModel

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Take-awaymessagefrominfanteyegazestudy

• Fundamental cause ofASDmaybe“payingattention tothewrong stuff ”– Thatis,neglect ofsocial input and emphasis on objectinput skewsbraindevelopment

– Failtodevelopfundamental structures needed toprocess complex social info

• Emergent networksresponsibleforsocialknowledge

• Isthere apotential window fordivertingdevelopment backontothe right course?

• Is18months toolate?

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Whatinterventionsmighttargeteyegaze?

• In infancy?Unknown asyet• Toddlers/preschoolers?

– Naturalistic/social communication/focusedstimulation types

– Behavioralinterventions– Technology/Videos?

• Older children andadults– Isittoolate?– Ifnot,

• Metacognitiveapproaches

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Interventionswithsupportingevidence

• Early intervention approaches– EarlyIntensiveBehavioralIntervention

– http://www.lovaas.com/– Pivotalresponse treatment

– http://education.ucsb.edu/autism/prt.html– EnhancedMilieuTeaching

– http://kc.vanderbilt.edu/kidtalk/f iles/presentations/Kaiser_AUCD%20Webinar_2_22_11.pdf– EarlyStartDenverModel

– http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/– DevelopmentalIndividualizedRelationship-based(D.I.R.Floortime)

– http://www.icdl.com/dirFloortime/overview/– SCERTSmodel

– http://www.scerts.com/– PictureExchangeCommunicationSystem

– http://www.pecsusa.com/– HanenMorethanWords

– http://www.hanen.org/Home.aspx– JASP/ER:Jointattention,StructuredPlay,EmotionRegulation

– http://www.ncbi.nlm.nih.gov/pubmed/22965298– http://www.slideshare.net/autismsciencefd/connie-kasariHewittMarch2016 55

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Jointattentionintervention• Kasari etal.(2007)

– Theory:socialengagementneededforlanguagedevelopmenttoprogressnormally

– Background:numerousstudiesshowdeficitinjointattentioninchildrenwithASD

– Jointattentionisfoundationofsocialengagement,soincreasingitshouldremediateand/orpreventsomeofthesocialandlanguageimpairmentsinASD

– Interventiontrainsparentstoengagechildreninplay-basedjointattentioninteractions

• (some similarity toFloortime, SCERTS)– Finding:increasedjointattentionANDincreasedvocabulary

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EarlyStartDenverModel

• Behavioral andnaturalistic combination• Developmental focus• Parent training• Relationship-based

– Fosteringsocial-cognitive, emotional, andcommunication development ineverydayhomeenvironment

– Dawson etal.(2010) – RCT showed gainsinIQ,adaptivebehavior, &autism diagnosis atfollow-up(compared totreatment asusual)

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IssuesininterventionforASDpastearlyyears

• Neurobiological– The longerasystemhasbeendeveloping,theharderitistocreatesystem-widechange• Behavioralproblemsbecomeentrenched• Problem-solvingstylerefinesitself

– Co-morbiddisordersmaybecomemoreacuteinlateryears

– Adolescentchangescancomplicatematters

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IssuesininterventionforASDpastearlyyears,cont.

• Families/school environments alsodeveloppatterns ofresponding, expectations

• Laterlanguageneeds tapintoweakestareas– Social-emotionalreciprocity– Inferencing– Executivefunctioning– Cognitiveflexibility,creativity

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InterventionapproachesforschoolagechildrenwithASD

• Theoreticalbases– Behavioral

• Claimsofthepotentialformassive, system-widechangenolongerpertainasinEIBI

• Behavioristsusethesetechniqueswithallages,butEIBItargetsearlydevel.

– Naturalistic• Challengetoidentifymotivatingnaturalcontextsandgetstudentstoengage

• Unclearifsimilar resultscanbeexpectedfromchild-centeredapproachasinyoungerages

– Metacognitive• Typicaleducationalapproach

– IDskill– Explainskill– Practiceskill

• Classicproblemsofgeneralization,maintenance,cognitivereadinessHewittMarch2016 60

ApproachestoImprovingSocialCommunicationinSchoolAgeChildreny in clude vide o mode ling

• Metacognitivepractice– Usessocial skills drills, but supports withdiscussion toassist in raising

awareness• Forhigher functioning, older individuals

– Winner’s social thinkingapproach fallshere» ThinkingaboutYou,ThinkingaboutMe» www.Socialthinking.com

– Social stories• attempt toraisemetacognitiveawarenessofsocial situations

– Social skills curricula• Manymaterialsexist

– Games– Workbooks– Songs

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Meta-cognitiveapproaches,cont.

• Discussingproblemobjectively• Autism SpectrumQuotient Testhttp://www.wired.com/wir ed/arc hive /9.12/a qtest.h tml

• Jackson (2002) “Freaks, Geeks,and Asperger Syndrome”• Myles, Trautman, &Schelvan (2004)

• RecentresearchapplyingcognitivebehavioraltherapytoASD:moresystematicandsophisticateduseofmetacognitiveapproach

• Evidence-based practice in psychology;SLP’s not trained– Though some implementation withf luency disorders

– EvidencethatCBTassistswithanxiety,includingsocialanxiety

• Sungetal. (2011);White etal. (2010);White etal. (2013);Woodetal. (2009)

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Approaches to ImprovingSocialCommunicationinSchool AgeChildren, cont.

• Modificationofenvironment– AAC– Visual schedulesandotherenvironmental cues– Sensorydiet– Training offamilies,educationalpersonnel,peers

– Training atclassroomor smallgrouplevel–CommunicationLab(Dodge,1998)–JarvisClutch,SocialSpy(Levine,2001)

» (alsoametacognitiveapproach)

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SocialCommunicationinASD: Challenges

• Problem– Socialskills,pragmatic languageimpairments arehallmarks ofautism spectrum disorders

– Insufficient controlled researchon interventiontechniques

• E.g.,SocialThinkingverypopular,but2015NSPreportexcludeditasanEBP

– Santhanam &Hewitt(2013)• Interviewed 8youngadultswithASD,foundalmostallsawlimitedbenefitfromorneedforintervention,yetallarticulatedfrustrationwithsocialandvocationalsuccess

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CriticalNeed forSocialCommunication:Outcomes forAdultswithASD

• Lowratesofeducational andvocationalattainment evenincognitively ableadultswith ASD– Nevill &White(2011)– Levy&Perry (2011)

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Adults with ASD:Underserved andUnderemployed

– Shattucketal.(2011),innationalsurvey,foundlowratesofserviceusagepost-highschool(ages19-23)

• 74%had SLPservices in highschool; only 9%didpost high school• Useofall support services dropped substantially

– Shattucketal.(2012),innationalsurvey,foundover50%ofyoungadultswithASDwerenotemployedorinschool

• 12.1%had attended college

“Youth withan ASDhad the lowest ratesof participationinemployment and the highest ratesof no participationcompared with youth inother disability categories” p.1042

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• Survey in Japan foundlower self-reported qualityoflife foradultswith high-functioning ASDthangeneral population– Kamio, Inada &Koyama (2012)

• Howlin et al. (2013)conductedstandardizedsurvey of60adultswithASDwith atleast averageIQ– Only10 ratedas“good orverygood”outcome– 60%ratedas“poor or verypoor” outcome

• Measures focusedonmentalhealth,employment,independentliving,socialrelations

QualityofLifeandASD

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PotentialReasonsforPoorOutcomes

• Co-morbid psychiatric disorders such asanxiety&depression; history of peer rejection

• Shtayermman (2007)• White, Ollendick, &Bray (2011)

• Undiagnosed orinsufficiently managed learningdisabilities and/or language impairments

• Lack of appropriate earlyintervention• Latestart• Lackofconsistency, eclecticism• Lackof intensity

• Forhigh-functioni ng individuals, talents andmanystrengthsmaymask significant difficulties

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Legal Changes from Secondary toPost-Secondary

• IDEAforK-12– Freeandappropriatepubliceducation

• ADAforwork andcollege– Reasonableaccommodations– Equalaccess– nomodificationtocurriculumorperformanceexpectations• conceptoflevelingtheplayingfield

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HowSLP’scanhelpimproveoutcomes

• Supportsandinterventionsweoffertargetkeyriskareas– Communication

• Oral and written– Social knowledge, social reasoning, social functioning– Linguistically and academically-related higher-order

cognition• Self-management• Planning• Task analysis and problem-solving• Strategies foracademic success

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Aspects ofASDSupporting CollegeSuccess

• Mayhavestronginterest insubject ofstudy• Relevantspecial talents• Averagetosuperior intellectual ability

– writing,drawing,mathematics

• Committed tofollowing rules• Mayenjoyreading, intellectual pursuit

– Notasdistractedbysociallife…

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Aspects ofASD notsupportingacademicsuccess

• Social– socialthinking, social communication– needforownspace

• Cognitive– Executivefunctioningdeficits

• higherorderplanning• decisionmaking• timemanagement• organization

– Rigidity• diff icultyadapting

– Informationprocessing• diff icultydealingwithcomplexinput• making rapiddecisionsinnewenvironments

• Emotional– anxiety– depression

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ASDand thepost-secondary environment• Collegeexpectations

– Independence• Sample abilities: cannavigate webtolocatesyllabi; canaccess e-mail forletterof accommodations,print,andsharewithprofessor;canmanage aplanneror

calendar– Problem-solving, higherorderplanning,decision-making

• Sampleabilities: canidentifystepsneededtocompleteassignment;candecidehowmuchtimetoallocatetostudyingversusrecreation;canidentifyneedtocontactprofessorandindependentlyf indouthowtodoso,thencarrythatout.

– Multi-tasking• Sample abilities: canlisten tolecture,andview PowerPoint,whiledecidingwhat

notestowritedown,andwritethem,whilescreeningoutbackgrounddistracters– Sensoryefficiency

• Sample abilities: canmanage tosleep andstudyindorm,despitelightingandnoiseissues; candeal withsmells andnoisesincafeteria

– Spatialreasoningandway-finding• Sample abilities: canlocate buildingsonacampusmap; canfolloworalorwrittendirectionstolocatenewplaces andsuccessfully navigate there independently

– Socialabilities• Sampleabilities: isawareofwhether someone isopen to interacting;knowswhat information toshare,when;knowshowtoshift registerfordifferent socialgroups

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MoreonSocialAbilities• Socialsuccess: thinkingaboutwhatothersare

thinking,allthetime,andusingthattomakedecisions aboutyourownactions– BasisofWinner(2007)approach.

• Usingthisinformation,inrealtime,topresentoneself positively,getsocialneedsmet– Requires micro-timing– Exhausting!

• Maybeveryunder-developedinmany18yearoldsonthespectrum

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ButifEBPisnotclearforchildren….

• Situation ismuch worseforadults

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BestpracticesforASD:stillrelevantforadults

• Individualized• Breaking downcomplex information, teachingnew skillsstep-by-step

• Repetition• Reducing auditory input/increasing visual input• Making explicit andobviouswhat isinferred andsubtle

• Expectation thatdevelopmental trajectory willnotbe rapid

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Transitionplanning

• Determining thetrue level ofindependenceof the student– Whatsupportsarepresent?– Howdothosecontrastwithwhatisavailableincollege?

• Realism isamust!

– Craftgoalsthattargetareaswheresupportsaremostlikelytobeabsentincollege

• Self-management, higher order planning

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ApproachestointerventionforyoungadultswithASD

• Where aretheneeds?– Startwithassessment

• Basics:– Interview withparents, case history– Interview withstudent

• Probing pragmatics– Double interview (Winner, 2007)

• Executive functioning– FAVRES

• Literacy/residual language impairments– Surprising number of studentshave dif f icultywithcollege level reading comprehension

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Communicationgoalsforcollege• Professionalcommunication:Goalareasfortransition

planning• Making phonecalls independently• E-mail

– Checking it– Courtesy/ responding– Interpreting nuances

» “shesaid‘get it to mewhen youcan’”• Off ice hours• Campus services• Reading a syllabus• Howtowork ingroups

– “That kid is anidiot but Iknow not to tellhim so”

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Communicationgoalsforcollege,cont.

• Socialcommunication:Goalareasfortransitionplanning– Livinginthedorm

• Roommates?– Approachingpeople

• How doyouknowwho youcantalkto?• High techcorollary:

– Who can you text

» And howo ften…– Fo l lowon so cial med ia

– Conversation• Topics

– App rop riateness» Erro rs o fq ual i ty

– Man ipu lation» Erro rs o fq uan ti ty

• Partner-focused questions– “The so cial fake”– Recip ro ci ty

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UsingWinner ’sSocialThinkingCurriculum

• Coreconcepts– Teaching socially oriented problem-solving– Step-by-step breakdown of howtounderstand whatothers arethinkingsoyoucan predictwhattheywilldo

– Quote fromfirstyearstudentwith ASD» “It’simpossible toknowwhatanyone is thinkingunless youareamind reader”

• Expected andunexpectedbehaviors• “Thinkingwithyoureyes”—howtoentersocialsituations

• Winner 2007aandbreferences inyourhandout

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Otherstufftothinkabout• Wayfinding

– Manywith ASDhavedifficulty with spatial reasoning;maybemasked if theyareused tosupports

• Clothingchoices– Clothing communicates….

• Vulnerabilitiestoexploitation– Goals forunderstanding when others are inappropriate

• Student Codeof Conductmay help• Videogameaddiction

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Unresolvedlearningdisabilitiesand/ormissingskills

• Higher order reading comprehension• Note taking• Studystrategies• Understanding collegelevelassignments

– “Idon’tknowwheretostart”• Timemanagement

– Usingaplanner– Technologyaids

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Managingco-morbidpsychiatricproblems

• Individuals with ASDathighriskforotherpsychiatric problems– Ifworkingwithapsychiatrist/psychologist,whatsupportsavailable?

– Whatisoncampus?• Oftencampusservicesintendedforshorttermcounseling

– Cantheytaketheirmedicationindependently?• Andwillthey?

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Anxietyanddepression

• Candestroy astudent’s college career– familiesmustbepreparedwithaplan– Studentsneedskillstoidentifyproblemandseekhelp

– Studentswiththisprofilemightconsidera2+2approach,startingatacommunitycollege

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CognitiveBehavioralTherapy

• Evidence-based practice formanypsychological problems– Well-documentedaseffectiveforsocialanxietyinASD• SeeHewitt2014forareview

– http://sig1perspectives.pubs.a sha.org /art icle.aspx?ar ticleid =1838333

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Whose collegecareerisit?

• Student musthaveinternal motivation– College isalow-structuredsituation

• Designedastransitiontoadulthood– Noamount ofemails, phone calls, textsandvisits fromparents cancreate the internal drive in thestudent if it islacking

• Neurobiologyrevisited:– All college students cangetexhausted andstressed– College students with ASDwill oftenbemoreso

» Plunged into stressful context ill-matched to their uniqueprofiles

• -àeverydaycanbeahugechallenge.

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Modeling inASD:Imitation• Imitationabilities

– LackofimitationisaredflagforASDintoddlers– But…superiorimitationabilitiesseeninotherrealms

• Echoedspeech• Savantabilities• “Hyper-imitation”

– SoisimitationimpairedinASD,oractuallysuperior?– Sowden,S.,Koehne,S.,Catmur,C.,Dz iobek,I.andBird,G.(2016),Intactautomaticimitationandtypical

spatialcompatibilityinautismspectrumdisorder:ChallengingtheBrokenMirrorTheory.AutismResearch,9: 292–300.doi: 10.1002/aur.1511

• Automatic imitation actuallysuperior• Sociallymediated imitativebehaviors impaired

– Notbecause imitationability lacking, butbecauseof dif f icultieswithcomplex,social situations

» Individualswithimpairedtheoryof mindfoundtobe“hyper- imitators”(Spengler, Bird,etal., 2010)

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ModelinginASD:Behavioraltreatments

• Verylargeliterature supports behavioralinterventions for ASD,especially EIBI– Reichow,B.(2012).Overviewofmeta-analysesonearlyintensivebehavioral

interventionforyoungchildrenwithautismspectrumdisorders.JournalofAutismandDevelopmentalDisorders,42(4),512-520.

– Keycomponentsofthistreatmentincludemodeling• Taskanalys is

• Repetition• Reward for correct imitation

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VisualSupports inASD

• Manyvisualapproaches– PictureExchangeCommunicationSystem– SocialStories– VisualTeaching– VisualSchedules

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SocialStories• Gray(2000)

– Simplesentences• Specif ic typesof sentences

– Pictures,ifneeded– Tailoredtochild– Specificguidelines:

• Listdesired behaviors,notprohibitedones• Give choices• Use “sometimes” ,“may” , etc.

– Helps decrease rigidity• Plantofadethemover time• More resourcesfromCarolGray:http://www.thegraycenter.org/index.cfm

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Morevisual approaches• Learningtoreademotionalcues

– Softwaregames• E.g.,Mind Reading• http://autismcoach.com/Mind%20Read ing.htm

• Communicatingaboutemotions– Visualcommunicationnotebooks

• Limited evidence foranyofthese, despitepopularity

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Visualapproaches, cont.

• Schedules, Planners, VisualOrganizers– Rationale

• Decreasesanxietybyincreasingknowledgeofwhattoexpect

• Incorporateslanguagetogowithsituation– Especially if student can read

• Decreasememoryburdensonstudent

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So,doanyoftheabovework?

• Evidence-basedpracticeforASDandpragmatics– Wearenotthereyet

• Bellini,Peters,Benner&Hopf (2007)– Metaanalysis ofsocial skills training studies forASD

» Little tono effect• Morehopefulresultsfoundinbelowreview:preliminarylowlevelevidenceshowsmodestgainsforsocialskillsgroupandindividualtraining,aswellaspeermodeling:

– Burgess,S.,&Turkstra,L.S.(2006).SocialSkillsInterventionforAdolescentswithAutismSpectrumDisorders:AReviewoftheExperimentalEvidence.EBPBriefs,1(4) ,1-21.

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SocialStories:Evidencelacking

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Case example: Social Stories (Gray, 2000)Daneshvar (2006)

Did not f ind social stories ef fect ive in teaching social behaviors to children with ASD

Scattone et al. (2006)Effect ive for 2 of 3 children in small study

Rust & Smith (2006)Review of studies to date found confounds

Other interventions at same t imeDifferent behaviors expected from caregivers

Designs weakGeneralization beyond duration of the study not invest igated

Some withdrawal designs suggest behavior reverts when story withdrawn

So,dosocial storieswork?

• Information isinconclusive• Important toincorporate themwithin amorecomprehensive behavioral plan

• Needtobewell-integrated intochild’senvironment, individualized totheir needs

• Not clearhow long-term theeffectsare

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Visual teaching strategy

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http://www.specialed.us/autism/printinst.htm

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WhyVisual

• Not necessarily becausevision inandofitselfbetter inASD– Someevidencesuggestsauditoryissues:

• Roth,D.A.E., Muchnik, C.,Shabtai, E., Hildesheimer, M., & Henkin, Y. (2012).Evidence foratypicalauditorybrainstemresponsesinyoungchildrenwithsuspectedautismspectrumdisorders.DevelopmentalMedicine & ChildNeurology,54 (1) ,23-29.

– However,natureofvisualinformationinherentlydifferentthanauditory

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Visualvs.Auditory

Visual• Persiststhroughtime• Canberepeatedexactly• Canusuallyprocess

separateelements,ifneedbe– E.g.,examining details of

shape orposition

Auditory• Transitory• Forspeech,exactrepetition

onlypossiblewithrecording• Cannoteasilyprocess

separatecomponents

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VisualSupports forASD

• Visuallyenhanced environments– E.g.,workbins,footprintstoshowwheretogo,TimeTimers

• Written and/or graphic instructions orprompts– E.g.,Red/yellow/green lights

• Visualschedules/visual activityschedules

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Modeling

• Providing intentionally planned inputdemonstrating somebehavior

• Strict definition involvesdemonstration alone,without instruction orfeedback– Thisishowitisusedinthemostnaturalisticlanguage therapyapproaches

– Modelingplusfeedbackusedinmorestructuredapproaches

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Staticvs.dynamic input

• Visualschedules/visual activityschedules arestatic– Evidence-basedpracticeforASD

• Knight, V., Sartini, E., & Spriggs, A.D. (2015).Evaluating visual activityschedules as evidence-based practice forindividuals withautism spectrumdisorders. Journalof AutismandDevelopmental Disorders, 45 (1) ,157-178.

– Goodforprovidingunchangingcuesforexpectedsequencesofactivities

– Decreaseneed toauditorypromptsandreminders– Increaseindependence

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Staticvs.dynamic, cont.

• Problem:– ImitationinASDnotimpairedatbasiclevel– Problemsarisewithcomplex,especiallycomplexsocial,activities

• Dynamicdemonstration– Livedemonstrationshavesameproblemsasauditoryinput• Transitory,hardtoreplicateexactly• ProcessinglimitationsofpersonwithASDmayconflictwithpatienceandexactnessofpersonprovidingmodel

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VideoModelingRationale

– Manybehaviorsarelearnedthoughobservationofothersintheworld

– Videoallowsonetofocusinondesiredbehaviorswithoutoutsidedistractors

– Allowsrepeated, identicalviewingstofocusonspecificdetails

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Modeling:AnEvidence-BasedPracticeforASD

• National StandardsProject (2015)identifiedmodeling andvideomodeling asevidencebased– http://www.nationalautismcenter.org/national-standards-project/

National AutismCenter (2015).Findings andconclusions: National standards project, phase2.Randolph, MA:Author.

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VideoModelingSupportintheLiterature:RecentExamples

• Playandplay-basedsocialbehaviors– Boudreau &Harvey,2013;Kourassanis, Jones, &Fienup, 2015;Sani-

Bozkurt &Ozen, 2015• Workplacesupports

– Burke etal. ,2013;Kellems, 2010• Socialcommunication,socialabilities

– Chen, Lee,&Lin, 2016;Hochhauser, Gal,&Weiss, 2015;Kabashi,2013;Mason etal. ,2012;O’Handley, Radley, &Whipple, 2015;Ozerk&Ozerk, 2015;Wilson, 2013a;Wilson 2013b

• Academicskills– MacDonald etal. ,2015;Yakubova, Hughes, &Hornberger, 2015

• Self-help,activitiesofdailyliving– McLay etal. ,2015– Spriggs, Knight, &Sherrow, 2015;

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However…• Applying rigorous criteria forestablishing anevidence-based practice, McCoyetal.(2016)didNOTfindvideo modeling forsocial skillstohavesufficient evidence– Issues:

• Lackofrigorousparticipantdescription/diagnosis• Failuretoestablishexperimentalcontrol

– Studiesshowedpositiveresults,butwerenotconductedinasufficientlyrigorousmanner,perproceduresadvocatedbyReichow (2011):

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VideoModeling• Videomodeling

• Models created byothersforclienttowatch– Commercial materials

» E.g.http:/ /www.modelmekids .com/– Some show “Don’ts” as well as “Do’s”– May confuse extremely literal children

• Teacher/clinician-created materials– Adult models

– Peer models

• Materials takenfrommassmedia orsocial media sites– TV, movies , YouTube

» Some great colleagues share resources :• https :/ / jillkuzma.wordpress .com/you tub e-vid eo-li nks -f or-soci al-skills /

• https :/ /www.pinterest.com/dow erassocia tes/video -m odeli ng/

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Videoselfmodeling• Modelscreatedbyskillfuleditingthatpurporttoshowthe

clientperformingthetargetskill– (Gelbar, Anderson, McCarthy, &Buggey, 2012)

• Theory– Increasedmotivationandattentionwhenmodelresemblesself– Providessupportiveinputofseeingoneselfproducetargetbehavior

– ‘IcandothisbecauseIalreadyhave’

• Hybridapproach• Createmodels, videoclient copying them, playvideo back,haveclient self critique, tryagain

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Creatingyourownvideos:TechnologyConsiderations

• Smart phones, tablets, computers withbuilt-incameras—video iseverywhere.– Easytotake– Easytoedit– Easytodelete?

• Issues toconsider:– Privacy:ifyouuseyourownsmartphone,doyouhavetechnicalabilitytodeleteavideosoitisnotrecoverable?

• Makesure it isnot synced toanycloud apps• Supposedly video deleted from iPad thatyou tookon iPad ispermanently gone ifyoudid notbackitup

– https://discussions.apple.com/thread/3747602?tstart=0

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Determininggoalsforvideomodeling

• Foryoungerchildren, basedon– Functionalimpact

• Isbehaviorsociallyisolating/imposingabarriertoaccesstocurriculumorotherlifecontexts?

• Degreeofvariationfromthenorm• Isitpotentiallydangerousfortheperson?

– E.g.,lackofknowledge ofappropriate topics maybenuisanceina3rd grader, butharassment ina10th grader

• Caregiverconcern

– Frequency

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Determininggoalsforvideomodeling,cont.

• Forolder children and adults, all on previous slide stillrelevant, and inaddition:

• Client’s perspective and needs– E.g.,Desiretochange

• I want tocommunicate betterwith myco-workers.– Goodbasis tobegin work

• I amnota smileyperson—it’s artificial and I need tobemyself. – Cannottarget goal nomatter howimpactful fortheclient’s problem.

– Note:Adolescentsmaynothavereadiness,whichmaybeneurological;mayneedmoreexecutivefunctiondevelopmenttohelpwithimpulsecontrolandtakingthelongview

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Makingvideos

• Short• Simple, with aclear scenario• Repetition• Client practice

– Videothose,asktocompare

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Privacyandsecurity

• Permission totakevideo?• Permission tokeepvideoforreuse?• Onschool/clinic equipment, isitsecurelystored? Could others accessit?

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Technicalconsiderations

• Lighting• Background• Audio quality• Editing

– iMovienottoohardtofigureout• Useofavatars,other cutting edgetech

– http://buggeyvsm.net/resources.html

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Groups

• Thecoolfactor– Whenisittoomuchfuntobepractical?

• Establish ground rules– Listofrulesandregs– Visualscheduleforvideomodelingsessions– Consequences

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Let’stryitout

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ContactInformation

• LynneHewitt• lhewitt@bgsu.edu• 419-372-6031

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