Combining Treatment Combining Treatment Approaches in Approaches in Working with Working with

Children with AutismChildren with AutismBy By

Tracy Vail,MS,CCC/SLPTracy Vail,MS,CCC/SLP

Letstalksls.comLetstalksls.com

Most Common Approaches Most Common Approaches UsedUsed

• Behavioral Approaches- ABA- Behavioral Approaches- ABA- Applied Behavior Analysis and Applied Behavior Analysis and Applied Verbal Behavior, TEACCHApplied Verbal Behavior, TEACCH

• Developmental Approaches- Developmental Approaches- SCERTS, Floortime/DIR, RDISCERTS, Floortime/DIR, RDI

Can We Combine Can We Combine Behavioral and Behavioral and Developmental Developmental Approaches?Approaches?

YES!!!YES!!!

General Language General Language CategoriesCategories

• Language used to meet the needs of Language used to meet the needs of the individualthe individual

• Language used for social Language used for social interactions and building interactions and building relationshipsrelationships

• Language used for “learning” or Language used for “learning” or academic settingsacademic settings

Factors to ConsiderFactors to Consider

• No single “program” works for all No single “program” works for all children to address all their needs.children to address all their needs.

• Every human being’s learning ability Every human being’s learning ability is a combination of internal and is a combination of internal and external factors.external factors.

• Motivation of the child is the most Motivation of the child is the most important factor to consider when important factor to consider when making treatment decisions.making treatment decisions.

Relevant Information About Relevant Information About Learners with AutismLearners with Autism

• They tend to have very analytical mindsThey tend to have very analytical minds• They tend to have unusual motivations and They tend to have unusual motivations and

consequently unusual reinforcersconsequently unusual reinforcers• They tend to be “rule based” learnersThey tend to be “rule based” learners• Their bodies experience the world in an Their bodies experience the world in an

unusual wayunusual way• Some are quite rigid and anxiousSome are quite rigid and anxious• They often have difficulty understanding the They often have difficulty understanding the

“rules” of social interaction and communication“rules” of social interaction and communication

So what…..Now what?So what…..Now what?

Use Whatever Works to Use Whatever Works to Teach the Most Teach the Most

Important Skills to each Important Skills to each Individual child at the Individual child at the

Given TimeGiven Time

So how do we know what’s most important?

Ask and ObserveAsk and Observe

• Ask the parents! What are their Ask the parents! What are their priorities?priorities?

• Observe the child- What areas are Observe the child- What areas are causing the child the most difficulty in life causing the child the most difficulty in life right now?right now?

• Look at where the child is currently Look at where the child is currently functioning and determine the necessary functioning and determine the necessary component behaviors/skills to meet the component behaviors/skills to meet the goals of the parents and child. goals of the parents and child.

• What are the goals of the family in 1 yr? What are the goals of the family in 1 yr? 5 yrs? 10 yrs?5 yrs? 10 yrs?

Developmental, Individual Developmental, Individual Differences, Relationship Based Differences, Relationship Based

Intervention, DIR/FloortimeIntervention, DIR/Floortime

• A warm and intimate way of relating to a A warm and intimate way of relating to a child. A floor time philosophy means child. A floor time philosophy means engaging, respecting and getting in tune engaging, respecting and getting in tune with the child in order to help the child with the child in order to help the child elaborate through gestures, words and elaborate through gestures, words and pretend play what is on the child’s mind. As pretend play what is on the child’s mind. As a technique it is a process that is used to a technique it is a process that is used to support the emotional and social support the emotional and social development of the child. (Greenspan, 2002)development of the child. (Greenspan, 2002)

This model serves as the context or “container” of the therapy we do. But what does it mean?

Hanen MethodHanen Method

• Teaching communication and play Teaching communication and play skills through adult- child skills through adult- child interactions. Parents/therapists are interactions. Parents/therapists are to: to:

• Observe, Wait and Listen (OWL)Observe, Wait and Listen (OWL)• This approach is very similar to DIR This approach is very similar to DIR

in that the child leads and teaching is in that the child leads and teaching is conducted based on the interests of conducted based on the interests of the child.the child.

Relationship Development Relationship Development InterventionIntervention

• A cognitive- developmental approach A cognitive- developmental approach designed to remediate Autism.designed to remediate Autism.

• Deals with autism as a neurologically based, Deals with autism as a neurologically based, information processing disorder.information processing disorder.

• Proposes to remediate the “Core Deficits” in Proposes to remediate the “Core Deficits” in Autism including motivation, communication, Autism including motivation, communication, emotional regulation, episodic memory, emotional regulation, episodic memory, rapid attention shifting, self-awareness, rapid attention shifting, self-awareness, appraisal, executive functioning, flexible appraisal, executive functioning, flexible thinking, and creative problem solving.thinking, and creative problem solving.

Great stuff based on research by many in the field but what do these “core deficits” mean? How do we know when these skills have improved? What is the child doing? How can we measure it? AND, is it really necessary to spend thousands of dollars being trained to address these issues?

Behavioral ApproachesBehavioral Approaches

• Scientifically validated based on many Scientifically validated based on many years of research.years of research.

• Based on measurable behaviors either Based on measurable behaviors either internal or observable.internal or observable.

• Based on the “laws of learning”Based on the “laws of learning”• Places the responsibility of learning on the Places the responsibility of learning on the

“teacher” rather than the student“teacher” rather than the student• Many “faces” to behavioral interventions. Many “faces” to behavioral interventions.

Not all programs look alikeNot all programs look alike• Data driven program decisionsData driven program decisions

Applied Verbal BehaviorApplied Verbal Behavior

• Based on the research of BF Skinner on Based on the research of BF Skinner on “why” people communicate“why” people communicate

• Language is categorized into verbal Language is categorized into verbal operants or functionsoperants or functions

• Language is taught as a behavior with Language is taught as a behavior with specific teaching procedures usedspecific teaching procedures used

• Both natural environment teaching and Both natural environment teaching and intensive teaching are used based on the intensive teaching are used based on the age and skills of the childage and skills of the child

• Resources: Educate Toward Recovery by Resources: Educate Toward Recovery by Robert Schramm, Assessment of Basic Robert Schramm, Assessment of Basic Language and Learning by James Language and Learning by James Partington and Mark Sundberg.Partington and Mark Sundberg.

TEACCHTEACCH• The long-term goals of the TEACCH approach are both skill The long-term goals of the TEACCH approach are both skill

development and fulfillment of fundamental human needs such development and fulfillment of fundamental human needs such as dignity, engagement in productive and personally as dignity, engagement in productive and personally meaningful activities, and feelings of security, self-efficacy, meaningful activities, and feelings of security, self-efficacy, and self-confidence.  To accomplish these goals, TEACCH and self-confidence.  To accomplish these goals, TEACCH developed the intervention approach called “Structured developed the intervention approach called “Structured Teaching.”  Teaching.”  

• The principles of Structured Teaching include:The principles of Structured Teaching include:– Understanding the culture of autism. Understanding the culture of autism. – Developing an individualized person- and family-centered Developing an individualized person- and family-centered

plan for each client or student, rather than using a standard plan for each client or student, rather than using a standard curriculum. curriculum.

– Structuring the physical environment. Structuring the physical environment. – Using visual supports to make the sequence of daily Using visual supports to make the sequence of daily

activities predictable and understandable . activities predictable and understandable . – Using visual supports to make individual tasks Using visual supports to make individual tasks

understandableunderstandable(TEACCH Website)(TEACCH Website)

The Language We UseThe Language We Use

• Often it isn’t what we do but how we talk Often it isn’t what we do but how we talk about what we do that makes approaches about what we do that makes approaches seem so different.seem so different.

• The language we use to talk about what The language we use to talk about what we do should be precise, agreed upon and we do should be precise, agreed upon and based on “observable” or “measurable” based on “observable” or “measurable” change.change.

• As SLPs we are charged to provide As SLPs we are charged to provide “evidenced based practices”. Show me “evidenced based practices”. Show me the data!!the data!!

SamSam

What did you observe with What did you observe with Sam?Sam?

• He remained engaged He remained engaged with the instructor for 3.5 with the instructor for 3.5 minutes.minutes.

• He requested using He requested using gestures 4 times with no gestures 4 times with no prompting.prompting.

• He imitated body He imitated body movements twice with no movements twice with no prompting.prompting.

• He looked at the instructor He looked at the instructor twice and smiled.twice and smiled.

• He laughed in response to He laughed in response to the instructors actions the instructors actions twice.twice.

• He initiated a social game He initiated a social game twice with no prompting.twice with no prompting.

• He shared affectHe shared affect• He shared attentionHe shared attention• He both opened and closed 5 He both opened and closed 5

circles of communicationcircles of communication• The instructor followed the The instructor followed the

child’s leadchild’s lead

• He demonstrated a He demonstrated a preference to engage in a preference to engage in a regulatory pattern with regulatory pattern with ongoing variationsongoing variations

• He regulated his actions to He regulated his actions to maintain social coordinationmaintain social coordination

• He responded to guides role He responded to guides role actions to maintain the actions to maintain the regulatory status of the pair.regulatory status of the pair.

Children are Complete Children are Complete Human BeingsHuman Beings

• They have a right to communicate to get They have a right to communicate to get their needs mettheir needs met

• They want and need successful They want and need successful relationships in their livesrelationships in their lives

• While they have some similarities, they all While they have some similarities, they all have unique needs that should be have unique needs that should be addressedaddressed

• Each family structure is different and has Each family structure is different and has unique priorities and needsunique priorities and needs

• Child and family needs will change over Child and family needs will change over time and programs need to reflect thattime and programs need to reflect that

Early LearnersEarly Learners

• Build trust/relationship by being Build trust/relationship by being predictablepredictable

• People are fun and “talking” is funPeople are fun and “talking” is fun• ““Talking” is useful- I talk, I getTalking” is useful- I talk, I get

Use a combination of principles from Use a combination of principles from DIR, Floortime and VBDIR, Floortime and VB

Build Context/Motivation to Build Context/Motivation to CommunicateCommunicate

Communicating Before Communicating Before TalkingTalking

Use MusicUse Music

Use BooksUse Books

Shape Speech in the Shape Speech in the Context of RequestingContext of Requesting

Teach Them a Way to Teach Them a Way to CommunicateCommunicate

Intermediate LearnersIntermediate Learners

• Advance language and literacy skillsAdvance language and literacy skills• Continue to include relationship Continue to include relationship

developmentdevelopment• Include intensive teaching based on Include intensive teaching based on

the needs of the childthe needs of the child• Expand play skills Expand play skills

Teaching Mastered Skills in Teaching Mastered Skills in Intensive Teaching Intensive Teaching

Expand Play SkillsExpand Play Skills

Advanced Language Advanced Language LearnersLearners

• Higher Level Language SkillsHigher Level Language Skills• Continue to build relationshipsContinue to build relationships• Problem solving/negotiatingProblem solving/negotiating• Foster success in academic and Foster success in academic and

social settingssocial settings

Advanced Pretend PlayAdvanced Pretend Play

Problem Solving and Story Problem Solving and Story ComprehensionComprehension

Negotiating/Problem Negotiating/Problem SolvingSolving

Thanks for All You Give Thanks for All You Give to Children!to Children!