8/12/2012

1

Part II Treatment Options

Martha S. Burns, Ph.D.

September, 2012

Right now the research evidence points to value of ABA approaches and promising new areas for intervention: ◦ perceptual training and the mirror neuron system in

young children Interactive play

Imitation

◦ mentalizing and other prefrontal lobe functions as the children mature TOM

Working memory

Maestro S et al Psychopathology 38(1): 26-31, January 2005

87.5% display symptoms in first year of life ◦ Withdrawn

◦ Displaying poor social initiative

◦ Lack of emotional modulation

8/12/2012

2

Zwaigenbaum et al International Journal of Developmental Neuroscience, 23(2-3), April-May, 2005

Marked passivity and decreased activity at 6 months

Followed by extreme distress reactions

Tendency to fixate on particular objects in the environment

Decreased expression of positive affect by 12 months

Johns Hopkins University Study Prospective, longitudinal design in which 125 infants

at high and low risk for autism were tested from age 14 to 36 months.

Comprehensive standardized assessments included measures of social, communication, and play behavior

Low-risk controls (n=18) and siblings of children with autism, grouped on the basis of outcome diagnostic classification at 30 or 36 months: ◦ autism spectrum disorders (early diagnosis, n=16; later

diagnosis,n=14), ◦ broader autism phenotype (n=19), and non–broader autism

phenotype (n=58).

Results: Social, communication, and play behavior in the early-diagnosis group differed from that in all other groups by 14 months of age.

By 24 months, the later-diagnosis group differed from the non–autism spectrum disorder groups in social and communication behavior, but not from the early-diagnosis group.

Examination of growth trajectories suggests that autism may involve developmental arrest, slowing, or even regression.

8/12/2012

3

Compared with the later-diagnosis group at 14 months of age, the early-diagnosis group produced significantly less frequent ◦ shared positive affect (P=.002),

◦ Initiation of behavior regulatory bids (P=.001),

◦ and initiation of joint attention bids (P=.009),

◦ as well as a smaller inventory of gestures and consonants (all P=.001) (Table 2).

By 24 months, these ASD groups exhibited similar frequency and diversity of social, communication, and play behaviors. Landa, et al., 2007 Figure. Developmental change of the 5 groups from 14 to 24

months of age on the Communication and Symbolic Behavior Scales

Developmental Profile

(CSBS DP) for frequency of shared positive affect (A), frequency of initiation of joint

attention bids (B), inventory of gestures

8/12/2012

4

Published April 28, Journal of Pediatrics

5 minute checklist for pediatricians

10,479 babies screened at one year checkups

24 questions

Accurately predicted problems in 75% of children (184)

False alarms for 25% ◦ Lack of shared attention (babies should try to pull

your attention to their world

Lack of shared enjoyment – may smile at mom but not engage if other people play peek-a-boo

Repetitive behaviors like spinning a car wheel rather than play with the car

Language problems seen with any of the above

Possible mechanisms of recovery include: ◦ normalizing input by forcing attention outward or

enriching the environment;

◦ promoting the reinforcement value of social stimuli;

◦ preventing interfering behaviors;

◦ mass practice of weak skills;

◦ reducing stress and stabilizing arousal.

Improving nutrition and sleep quality is non-specifically beneficial.

8/12/2012

5

The presence of seizures, mental retardation and genetic syndromes are unfavorable signs,

whereas head growth does not predict outcome.

◦ Residual vulnerabilities affect higher-order communication and attention.

Tics, depression and phobias are frequent residual co-morbidities after recovery

Getting started ◦ Language & early imitative routines

Functional Communication (PECs)

Gestalt Processing

Visualization

Until controlled research is available – continue to use tried and true interventions ◦ ABA to control behavior and establish task

orientation – especially with severe symptoms ◦ Naturalistic “play approaches” like DIR (Floortime)

Right now the research evidence points to promising new areas for intervention: ◦ perceptual training and the mirror neuron system

in young children Interactive play – DIR is a good formalized approach

Imitation – RDI is a good formalized approach

Interest in and attention to speech vs. nonspeech stimuli

Interest in and attention to faces

Interest in and attention to body parts

Tolerance of holding, rocking, and stroking

8/12/2012

6

Henry OT

Sensory Integration activities for young children

Until controlled research is available – continue to use tried and true interventions ◦ ABA to control behavior and establish task

orientation – especially with severe symptoms ◦ Naturalistic “play approaches” like DIR (Floortime)

Right now the research evidence points to promising new areas for intervention: ◦ perceptual training and the mirror neuron system

in young children Interactive play – DIR is a good formalized approach

Imitation – RDI is a good formalized approach

Interest in and attention to speech vs. nonspeech stimuli

Interest in and attention to faces

Interest in and attention to body parts

Tolerance of holding, rocking, and stroking

Sensory Integration activities for young children ◦ Engaging the baby

Respect the baby’s sensory preferences – then incorporate what he likes into activities

Interact a few inches away

Match your loudness and animation to his preferences

Rub, deep touch, tickle, to see what she likes and tolerates

8/12/2012

7

If the tot prefers movement to interaction ◦ Follow the baby and join in his activity –

remember that imitation builds mirror neurons

◦ Try swings or lifting

◦ Try to encourage behaviors that initiate (to engage mirror mechanism) Return to the activity

Order of activity events

Interaction

◦ Block stereotypic/repetitive behaviors with interceptive actions

Language & early imitative routines for Mirror

Mechanism ◦ Peek-a-boo

◦ Nursery rhymes and songs with gestures ◦ Music to words

◦ Animal sounds to words

Functional Communication (PECs) Visualization

Movement tools ◦ Bouncing, swinging, pushing, pulling, slides – always face

child and stress imitation of facial expression and movement sequences

Muscle tools ◦ Tug of war, weighted toys, mini-trampolines and inflatable

jumpers

Touch tools ◦ Hand fidgets (Henry, 2001), putty or play dough,

temperature (cool and warm water)

Ear Tools – music and animal sounds Eye Tools – adjust the lighting, facial puzzles Mouth Tools – chew tubes, mouth fidgets (Henry,

2001) “Talk Tools”

Movement tools – slow rhythmic movements before tactile activities

Muscle tools – smash, pull and squeeze materials

Touch tools – vibrating toys, weighted blankets, play with varied textures, dress up,

Ear tools – use calming music

Eye tools – “What’s inside”

Mouth tools – mouth fidgets and bubbles

8/12/2012

8

Movement tools – start predictable and move to novel; piggy back rides; wrap tot in blanket and pull on the floor; up-over-around tunnels

Muscle tools – push a swing, pull a rope to make the swing move

Touch tools – allow a “blankey” and start movement snuggled in a blanket or bean bag chair

Ear tools – pair movement with songs Eye tools – hide and seek (well test) Mouth tools – only during therapy

Language

Visualization

Go to PECS if there is no language

8/12/2012

9

Use visual strategies to help with concepts of time, order and schedule

Monkey see (“look at me”) – Monkey do (“follow me”) ◦ See especially new research on imitative routines in

primates

M. Carpenter In S. J. Rogers, J. Williams, Eds. (Guilford, New York, 2006), pp. 48–70 In humans, imitation is not only a way of

acquiring new behaviors, but also is a way of connecting with others and aligning oneself with them—of communicating one’s likeness and affinity to others

Social function of imitation is apparent from a very early age, when human children copy others closely

even in problem-solving tasks when copying the particular actions the demonstrator used often is not necessary to achieve the instrumental goal

8/12/2012

10

Annika Paukner Stephen J. Suomi, Elisabetta Visalberghi, Pier F. Ferrari

Science 14 August 2009: Vol. 325. no. 5942, pp. 880 - 883

Session 1 and 2 Give the child a ball or a favorite toy

Do not ask the child to do anything with the toy ◦ Let the child play with the toy or ball anyway she

wants ◦ Imitate what the child does – if he lines up trucks

– you do the same – if she chews the ball you do the same

◦ After a short period where you imitate and the child seems interested in your imitations – give the child a token for each time the child attends to your imitation

◦ The child can turn in the tokens at the end of the session for a reinforcer

Session 3-4 After a few sessions where the child has begun to attend to adult imitations ◦ Imitate the child first then add a new action or new

toy (DIR – bridging) If the child lined up trucks, you line up trucks but then

move one truck along a line or make a truck sound

If the child imitates your added action, give him a token, if not continue to imitate the child but give her a new toy

Sessions 5-6 ◦ During imitative play – try to encourage imitative

routines: movements (like Patty Cake) or gestures (like so big) or animal behaviors or rhythm marching bands

Sessions 7-8 ◦ Begin to stress imitation of facial expressions

during – peek-a-boo may help get this started

Sessions 9+ combine imitative routines using tokens as rewards for attention and imitation

8/12/2012

11

Facial expression ◦ Use photos imitating the expression and asking the

child to do so as well

◦ Look at animal and insect photos and try to imitate their expressions (eg. fish face, beaver face, monkey grin, etc.)

Bodily movement ◦ Have young children act like an animal and guess

the animal - Elephant walk, bird flight, monkey scratch, etc.

There are no visual perceptual programs designed to improve perception of facial expression or biological movement ◦ Beware of visual therapies that stress eye

tracking, eg. through optometrists – there is no evidence of any value in ASD

The most thoroughly researched approach for building auditory perceptual skills is Fast ForWord Language.

Earobics may be helpful but at this time there is no specific research with autism spectrum

Give picture to adult to get item desired

Select desired picture then give to adult

Select picture, generate phrase, give to adult

Seek PECs book, select picture, generate phrase and/or sentence, give to adult

8/12/2012

12

PECS – Picture Exchange Communication

AAC – Augmentative & Alternative Communication (including voice-output)

Sign Language – SEE / ASL

8/12/2012

13

Red plus Green tree

The big dog jumps

article adjective

noun verb

8/12/2012

14

Try auditory processing computer-based interventions ◦ Listening programs ◦ Fast ForWord Basics to Language ◦ Reading Assistant

Visual processing programs ◦ Mind Reading – Interactive Guide to Emotions

http://www.jkp.com/mindreading/demo/content/dswmedia/loader.htm

Begin organized movement interventions – smart moves

Emphasize mirror neuron activities ◦ RDI ◦ Imitative visual motor routines

Executive function tasks especially stressing working memory

The Interactive Guide to Emotions - Version 1.3

Simon Baron-Cohen

http://www.jkp.com/mindreading/demo/index.php

http://www.jkp.com/mindreading/demo/

Brain HQ (from Posit Science)

Demo

8/12/2012

15

Techniques to empower parents to develop mirror neuron building interactions with their children

http://www.rdiconnect.com/

4130 Bellaire Boulevard Suite 210

Houston, Texas 77025

Toll-Free: 866.378.6405

Phone: 713.838.1362

Fax: 713.838.1447

Demo

www.socialthinking.com

Taking perspective – she was a pioneer in working on TOM with adolescent ASD

Humor – she believes that children with ASD need to learn to laugh at themselves

Social Skills – unlike the social scripts she advocates developing a view of the other, how they think and what they might think of you

8/12/2012

16

1. Improving the awareness of self and others,

including physical appearance, likes, dislikes and

problem solving;

2. Allowing clients to assess their own

communication skills;

3. Taking the client through eight levels of body

language;

4.'Talkabout the way we talk' improving

paralinguistic skills;

5. Taking the client through the processes needed to

improve conversational and listening skills;

6. Awareness and use of assertiveness skills.

Practical and user-friendly, this comprehensive

workbook is an essential resource for therapists

running social skills groups.

Talkabout

Visual Thinking Strategies For Individuals With

Autism Spectrum Disorders

In this groundbreaking book, Arwood, Kaulitz and

Brown explore and explain how persons at

different levels of sensory and cognitive

functioning need visual information presented

differently to facilitate their individual thinking and

learning. This information helps us all (parents

and professionals) to shift our perspective away

from using visuals that make sense to us, to

creating visuals that are designed to facilitate a

student's understanding. This book clearly demonstrates the `science' behind the art!"

Pathways for Learning I and II

An outstanding resource of VISUAL ORGANIZERS that helps children better recognize the predictable patterns within classroom language

experiences. This resource provides visual organizers for use with:

Vocabulary and Concept Development

Associations

Categories

Multiple Meaning Words Analogies

Compare/Contrast

Cause and Effect

Literature note taking and comprehension: Organizing Story Details, Main Ideas, Story Sequence and Chapter Summaries

Story Elements: Characterizations, Setting, Conflict, Theme Analysis,

Context and Significance Classroom Content: Lesson Preview/Review, Topic/Lesson Summary,

Outlining Notes, Unit/Chapter/Lesson Connections/Current Events, Historical People/Event Outlines, Geography Themes, Biography

Brain Cogs(2001) – Learning and Study Skills software for grades 4-8 ◦ FableVision – 44 Pleasant Street, Watertown, MA

02472, 617.926.1231, www.fablevision.com ◦ Teach strategies for remembering, organizing*,

prioritizing*, shifting*, and checking (*great for older NVLD, HFA, and Asperger’s children)

8/12/2012

17

Brain Fitness games for kids

http://www.lumosity.com/

New York Times Puzzle page ◦ Visual set puzzle for adolescents

◦ http://www.nytimes.com/ref/crosswords/setpuzzle.html

Barb Kirby, OASIS, www.aspergersyndrome.org, Co-author, the OASIS

guide to Asperger Syndrome.

Jennifer Abbott Bulka, M.A., SLP, www.talkingplayhouse.com

Understanding the main idea Explaining the main idea Synthesis of information – including part-

whole relationships and categorization Story formation Planning Problem solving Gestalt in conversations – the social

importance of gestalt processing

8/12/2012

18

Listen/read description of an item/activity – identify one word main idea (ex. Playing outside and making a man out of snow = snowman)

Tell story – identify one word/phrase for main idea

Give steps – identify task

Tell story – answer questions about the main idea

Tell story – generate main idea sentence

Tell story – generate summary

Describe the necessary steps for a task

8/12/2012

19

Part-whole relationships

Identify the parts for a given item

Identify the item when given list of parts

Categorization

Identify category for list of items

List items in a given category

Identify why an item does or does not go into a given category

Select topic/theme

Select main idea

Generate vocabulary

Generate sentence for each vocabulary word

Connect sentences to main idea

Cat Food

Fish Toys

Dog Vet

Story:

I want to have a pet. I could have a cat or a dog. I

could also have a fish. I will need to feed my pets.

Pets like to have toys, like a ball. If my pet gets sick I will take it to the Vet.

Simple story formulation activity

Who is this story

about? What is this story

about?

Describe what happened?

Describe when it happened?

Describe where it happened?

Describe how or why it happened?

Story Map

Copyright by Christine Brennan, MA CCC-SLP, 2006

www.brennanandburns.com

8/12/2012

20

Plan multiple activities to complete in sequence

Plan steps for each given activity

Review activities completed

Review steps completed

Refer back to main idea or purpose of plan

Use a visual schedule or visual choices

8/12/2012

21

The social importance of gestalt processing People communicate in stories Listen to a story and understand the main

idea / main topic Share a story of your own about the same

topic Staying on topic requires that the topic is

understood If the main idea is missed, reciprocal stories

or related comments and questions will be unrelated

8/12/2012

22

Speech production

Communication about items not present

Thinking about past / future events

Describing

Story telling

LIPS – Lindamood Phonemic Sequencing® Stimulates phonemic awareness Increase awareness of the mouth actions that

produce speech sounds Becomes the means of verifying sounds

within words Impacts speech comprehension, reading,

spelling, and speech production

Look at a picture or object, describe it when it is gone

Think of an item and describe it’s visual characteristics

Drawing /discussing people and items Recalling and describing other places Describing activities Touching (but not looking at) an item and

describing shape, color, size

8/12/2012

23

Use calendar, planner, schedule

Categorize activities by month, season

Teach time concepts

Teach “when” questions

Teach story telling about past events

Teach story telling about future events

Practice asking questions about other people’s past and future events

When ?

Before / After

Today / Yesterday & Tomorrow

8/12/2012

24

8/12/2012

25

Category

Appearance

Size

Location

Function

Association

Generate a topic

Generate related items

Talk about event(s) in story

Draw a picture about the story – show all related items as identified

8/12/2012

26

Voice output

Signed Exact English vs. ASL

Idiomatic signs

Sign + verbal

+ AAC

Key signs to teach: more, all done, help, drink, cookie, eat/food, play, open

Teach signs for each child’s most motivating items

Auditory Processing

Social Thinking – part 1 Also see Michelle Garcia Winner’s

www.socialthinking.com

Motor Planning

Abstract Language

Executive Functioning

Theory of Mind

Speech-sound discrimination

Auditory memory

Sequencing

Language processing

Conversation processing

Speed of processing

8/12/2012

27

Discrimination of speech sounds letters and letter sounds

Minimal word pairs

Sentences with minimal word pairs

Fast ForWord Language / Literacy

Digit span, word span, sentence recall

Story recall

Visual recall

Work on building auditory memory starting at current level of child

Sequencing / Temporal vocabulary: first, next, last, when, then, after, before, during, will,

did,

Auditory directions with sequence order

Auditory description of event(s) with steps

Listening to speech sounds, synthesizing into word

Recall (auditory presentation) words, sentences, information in order or in reverse order

Listen to partial sequence and complete

Comprehension of various language structures

Comprehension of stories

Comprehension of questions

Discrimination of similar sentences

8/12/2012

28

Processing and comprehending:

statements made by others

questions asked by others

stories shared by others

comments made by others

Fast ForWord Language / Literacy

Eye contact

Developing reciprocity

Developing empathy

Basic social skills ◦ Responding to others

◦ Making comments

◦ Asking questions

◦ Turn-taking

8/12/2012

29

This is you.

What do you think about?

What do you like to talk about?

Conceptual reciprocity

This is a dog.

What do dogs think about?

Require eye contact following a motivating request

Don’t request eye contact during listening activities

Practice eye contact during conversational activities

Focus on facial interpretation during conversation activities instead of focusing on eyes

8/12/2012

30

My eyes show what am thinking about

(Look at item in room, like your watch)

What am I thinking about – the time

(Look at child)

Ask again - What am I thinking about?

Practice using eyes to determine what each other is looking at

Practice “Guess what I did…”

Formulate stories about personal events

Share opinions and preferences

Practice sharing and asking about preferences

Practice sharing and asking about events and opinions

8/12/2012

31

Responding to others Answering questions, making comments

Making comments Commenting on play, actions, statements, feelings,

opinions, sharing stories

Asking questions About preferences, activities, people, events

Turn-taking (game related and task related)

Conversational reciprocity

Ask people about the things they want to talk about

Ask people about the things they like

Share what you think about

Ask questions about the things you like

Share opinions and ask others about their opinions

This is Christine.

What does she think about?

What might she talk about?

8/12/2012

32

Smart Moves ◦ Demo

Interactive Metronome

8/12/2012

33

Inferences

Reading between the lines

Expressions

Interpreting behavior of others

Meaning from context

Ambiguous language

What, who, where am I? I am a red fruit that grows on a tree? What

am I? apple Open wide and relax. I’ll take a look at that

sore tooth. Who am I? dentist My latest book is a children’s story. It will

be published next month. Who am I? author

First I grab a tray. Then I get in either the hot or cold food line. Where am I? cafeteria

There are so many exhibits to see. Let’s find out where the dinosaur skeletons are. Where am I? museum

Inferences about where

Inferences about when

Inferences about reasons

Inferences about feelings

Predictions

Inferences from reading

Nonverbal language

Inferences from pantomime

Speaking style

Using what you know to guess what you don’t know

Deductive reasoning tasks / activities

Clue, Guess Who, Battleship, Breaking the Code

Understanding sarcasm

Using sarcasm

8/12/2012

34

Idioms

What they mean

What they don’t mean

Guessing what they mean

Using idioms correctly

Interpreting unknown idioms in context

Making observations about others behaviors Explaining the behavior of others

Actions

Statements (questions and comments)

Body language / gestures

Tone of voice

Facial expressions and eye contact

Lying

Hypothesizing why someone might be doing a given behavior

IDEAS for: Abstract Language Interpreting behavior of others

• Make observations about characters on TV show or movie

• Explain the behavior of the characters • Describe their Actions

• What did they say or ask

• Describe their body language / gestures

• Describe their tone of voice

• Describe their facial expressions and eye contact

• Why did the character do those things

• What was he / she feeling

• What did he / she want

Vocabulary meaning in context

Interpreting idioms in context

Interpreting sarcasm in context

Interpreting inferences in context

Reading activities

Picture activities

Conversational activities

8/12/2012

35

Interpreting ambiguous vocabulary (i.e. homonyms)

Interpreting ambiguous sentences (i.e. “A grandmother of five hits a hole in one!”)

Action monitoring (emotional regulation)

Self knowledge (emotional awareness)

Person perception

Mentalizing

Outcome monitoring

Self-monitoring: control of initiated actions and cognitive processes and awareness of errors

Increase awareness of self Increase general monitoring Make errors a game / make errors ok Practice reviewing actions Practice awareness and control of initiating

actions and processes Announcing what you will do next, explaing

actions step-by-step Giving clear directions / have child model

steps and actions for adult

8/12/2012

36

Children with ASD, especially Asperger’s may appear to over or under react to different situations

Reviewing the concept of “Putting things in Perspective” can be helpful

Make hierarchy of problems Discuss severity of problems Discuss how to express opinions as they

relate to perspective

Who I am?

Moods (positive and negative)

Beliefs ◦ Opinions

◦ Opinions of others

Desires (things, events, actions, people…)

Sensations (pleasant and unpleasant)

Personality – How am I different from other people

Begin developing flexibility early

Greenspan emphasis on “bridging”

Video

Say “day” Say “night”

8/12/2012

37

Emotion vocabulary

Emotions and causes

Feeling are ok, even if we don’t like them

Asking for help

Practice ID own emotional state

Practice expressing own emotional state

Problem solving as related to emotional difficulties

Do social stories or choices for behavior for different feelings

Example:

When I feel angry I can

Ask for help

Take a break

Go for a walk

Understanding motivation / nonverbal cues

8/12/2012

38

Forming impressions of other people Using observations of behavior to make

inferences Understanding motivation and how it affect

people Practice drawing inferences about the

personality and the emotional states of others

Explain the nonverbal cues used to drawing inferences about others

Practice interpreting nonverbal cues

The process of making sense of mental states in yourself and in others

Emotion vocabulary Identifying your emotional state Recognizing emotion states of others Hypothesizing why a person is behaving a

given way Role playing how to respond to other

people’s emotions Practice expressing your own emotional

state Practice explaining why you feel a given way

Anticipating consequences of various actions (what might happen if…)

Explaining connections between an action and a consequence (what happened and why?)

What did you do and what was the result? Making good choices Making good plans Evaluating past choices and past plans Predicting problems / consequences

Predicting problems / consequences Evaluating Risk Decision Making

8/12/2012

39

Theory about the nature of the mind Refers to the ability to understand that

others have beliefs, desires and intentions that are different from one's own

Includes two facets: ◦ 1 - understanding that others have minds of their

own with different ideas, thoughts, wants, needs, emotions, and intentions

◦ 2 - being able to form hypotheses about others’ ideas, thoughts, wants, needs, emotions, and intentions

Deficits in social and emotional reciprocity probably stem from a problem in their development of Theory of Mind

1 - Sally puts her ball in the

box and then leaves the room.

2 - While Sally is away, Anne

puts the ball in the bag

3 - Sally returns for her

ball. Where will she look?

Individuals with deficits in theory of mind have difficulty with the following: ◦ Discriminating what others know versus what they

know ◦ Disrimination of themselves from other ◦ Taking the perspecive of others ◦ Interpreting actions of others ◦ Thinking about/considering differences of opinion ◦ Emapathy/sympathy ◦ Conversation skills ◦ Learning social rules

8/12/2012

40

Practice false-belief tasks

Discuss others people’s ideas, thoughts, wants, needs, emotions, and intentions

Practice forming hypotheses about others’ ideas, thoughts, wants, needs, emotions, and intentions

Play games in which one person knows something the other doesn’t

Children with ASD often have difficulty with social and emotional reciprocity

This is a result of poor theory of mind

They may lack the ability to express their emotions as well as the ability to interpret and react to the emotions of others

This combination of deficits may make an individual with ASD seem cold and detached

8/12/2012

41

Asking questions ◦ Good generic questions

◦ Questions for different groups of people (i.e. teacher, family, peers, new people)

◦ Listen and ask a related question ◦ Introducing questions (i.e. I like dogs. Do you have

a dog?)

◦ Asking about previous knowledge

What do you know about a person then generate a related question (i.e. Christine went to Washington, ask “How was your trip to Washington?)

Generating

Questions