The CARD The CARD Treatment ProgramTreatment Program

Center for Autism and Related Disorders, Inc

Doreen Granpeesheh, Ph.D.

GPL Conference

Anaheim, California

What is ABA? What is ABA?

The CARD Treatment ModelThe CARD Treatment Model

The CARD CurriculumThe CARD Curriculum

Case Study and DataCase Study and Data

Today’s DiscussionToday’s Discussion

What is ABAWhat is ABA

ABA is based on principles of Operant Conditioning Theory

Operant Conditioning Theory:

Human Behavior is affected by events that precede it (antecedents) and events that follow it (consequences)

Application of ABA to the Application of ABA to the Treatment of AutismTreatment of AutismSymptoms Classified as:

Deficits Language Play Social Skills Theory of Mind Executive Functions

Excesses Self Stimulatory Behs Maladaptive Behs

• Tantrums

• Aggression

• Noncompliance

Skill Repertoire Building Behavior Management

The CARD Treatment ModelThe CARD Treatment Model

ABA Foundation

Serve children from 18 mo – 8 yrs

Intensive treatment

Bi-Weekly supervision

Shift from home-based 1:1 learning to peer & community based learning opportunities

0

10

20

30

40

Year1

Year2

Year3

Year4

Allocation of Hours

Home-based School-based

The CARD Treatment Model:The CARD Treatment Model: Beginning LevelBeginning LevelServices:

30-40 hours of 1:1 in-home behavioral interventionTargets:

Build a relationship with the child Increase child’s initiation with us Increase Compliance Language Training - Requests

(Mand Training) Language Training - Receptive &

expressive object & action labeling (Tact Training)

Imitation, toy play, & pretend play Self-help skills

The CARD Treatment Model:The CARD Treatment Model: Intermediate LevelIntermediate Level

Skills Taught Asking Wh Questions Conversational language Generalize language to play

& peer situations Emotion recognition Sociodramatic & imaginary

play Basic cause and effect Emphasis on generalization

& playdates begin

Services20-30 hours of 1:1 in-home intervention5-10 hours of preschool with a CARD shadow targeting social skills & generalization

The CARD Treatment Model:The CARD Treatment Model: Intermediate Advanced LevelIntermediate Advanced Level

Skills TaughtClassroom routinesFollowing complex & group

instructionsMaking inferencesObservational learningSocial skills and peer interactionPragmatic Language (e.g., introducing a topic, maintaining a conversation)Self-monitoring, Planning and Problem Solving

Services 20 hours of therapy per week:

Includes 1:1 & playdates in home & in the community 20 hours school with shadow

The CARD Treatment ModelThe CARD Treatment ModelAdvanced LevelAdvanced Level

Services

5 - 10 hours per week at home (fading out)

Gradual fading of school shadow

Skills Taught Social perspective taking Academics Continued self-

monitoring Advanced pragmatics

(e.g., detecting sarcasm) Completion of parent and

teacher training

The The CARD CARD

CurriculumCurriculum

The CARD CurriculumThe CARD Curriculum

Language PlayTheory

ofMind

Social Skills

Social Skills

ExecutiveFunction

Self Help&

Motor Skills

School Skills

The CARD Curriculum: The CARD Curriculum: Some general pointsSome general points

The child’s individual learning style is considered before particular skills are introduced

Visual Modification suggestions in each program, for visual learners

Verbal Behavior framework used in all language programsGeneralization Emphasized from very

early on At least 5

generalization ideas for each skill taught

Flexibility worksheets for each Language program to ensure generalization

The CARD CurriculumThe CARD Curriculum

Language PlayTheory

ofMind

Social Skills

Social Skills

ExecutiveFunction

Self Help&

Motor Skills

School Skills

The CARD CurriculumThe CARD Curriculum

Jody hands mom the blue crayon

3 crayons present & mom says, “give me blue”

Receptive

Jody matches blue cards3 color cards on tableMatching

Jody says, “blue”Mom asks, “What color is the sky?”

Conversatn

(Intraverbal)

Jody says, “blue”

Jody says, “blue paint”

Jody says, “blue”

Child’s Behavior

Mom says, “blue”Imitation

AntecedentFunction

Jody sees a blue carLabeling

(Tact)

Jody is ready to finger paint, but no paint

Requesting(Mand)

Language

Sample Program: Colors

The CARD CurriculumThe CARD Curriculum

Emphasis on ensuring spontaneity in Emphasis on ensuring spontaneity in language uselanguage use

Emphasis on teaching language that is Emphasis on teaching language that is functional in everyday situationsfunctional in everyday situations

Emphasis on generalizationEmphasis on generalization

Language

Overall Goals in Teaching LanguageOverall Goals in Teaching Language

The CARD CurriculumThe CARD Curriculum

Language PlayTheory

ofMind

Social Skills

Social Skills

ExecutiveFunction

Self Help&

Motor Skills

School Skills

The CARD CurriculumThe CARD Curriculum Play

Independent Play Tracking Beginning

Play

SymbolicPlay

ConstructivePlay

Imaginary Play

Sociodramatic Play

Practice Play

Games with Rules

FunctionalPretend Play

Target AreasTarget Areas

The CARD CurriculumThe CARD Curriculum Play

Features of a Comprehensive Play Skills ProgramFeatures of a Comprehensive Play Skills Program

Modeled after the development of play skills in Modeled after the development of play skills in typically developing children typically developing children

Breaks down each type of play into its own Breaks down each type of play into its own systematic and comprehensive programsystematic and comprehensive program

Sequential formatSequential format

Programs may be used individually, concurrently, Programs may be used individually, concurrently, or cumulativelyor cumulatively

The CARD CurriculumThe CARD Curriculum Play

Target mastered solitary play in Social Play program, to generalize with peers

The child generalizes the skill to social situations

Reinforce independent practice of play skill & track Independent Play to ensure spontaneity

The child rehearses the skill on their own

Our client imitates therapist/ parent in a 1:1 setting

The child observes & explores

Progression of play targets within CARD program

Typical Development of Play Skills

The CARD CurriculumThe CARD Curriculum

Pretend Imitation with Functional ObjectsPretend Imitation with Functional ObjectsPretend Receptive Commands with Functional Pretend Receptive Commands with Functional ObjectsObjectsVocalization of Pretend Play with Functional Vocalization of Pretend Play with Functional ObjectsObjectsExpressive Identification / NarrationExpressive Identification / NarrationCreation and Initiation of Pretend Play with Creation and Initiation of Pretend Play with Functional ObjectsFunctional ObjectsRequesting Pretend Play with Functional ObjectsRequesting Pretend Play with Functional Objects

Play

Sample: Functional Pretend PlaySample: Functional Pretend Play

The CARD CurriculumThe CARD Curriculum

Language PlayTheory

ofMind

Social Skills

Social Skills

ExecutiveFunction

Self Help&

Motor Skills

School Skills

The CARD CurriculumThe CARD Curriculum

Theory of mind or Social Cognition is concerned Theory of mind or Social Cognition is concerned with how children learn to conceptualize other with how children learn to conceptualize other people, growing an understanding of others’people, growing an understanding of others’

ViewpointsViewpoints ThoughtsThoughts

EmotionsEmotions IntentionsIntentions

TheoryOf

Mind

The CARD CurriculumThe CARD Curriculum TheoryOf

Mind

Social Cognitive Impairment in AutismSocial Cognitive Impairment in Autism

Inability to infer or empathize others’ desires / feelingsInability to infer or empathize others’ desires / feelingsInability to consider what others knowInability to consider what others knowInability to consider what others are thinkingInability to consider what others are thinkingInability to infer others’ beliefs / opinionsInability to infer others’ beliefs / opinionsInability to consider unintentional behaviorInability to consider unintentional behaviorInability to infer communicative intentInability to infer communicative intentInability to understand or engage in deceptionInability to understand or engage in deceptionInability to coordinate multiple social cues in a given Inability to coordinate multiple social cues in a given

social scenariosocial scenario

The CARD CurriculumThe CARD CurriculumTheory

of

Mind 9 Target Areas

Emotions

Desires

SensoryPerspectives

Knowing

PreferencesThinking

Beliefs

Intentions

Deception

The CARD CurriculumThe CARD Curriculum TheoryOf

MindSample Program: KnowingThe child learns that people know things based on the following tenets:The child learns that people know things based on the following tenets:Knowing from SeeingKnowing from Seeing

Knowing from HearingKnowing from Hearing

Knowing from SmellingKnowing from Smelling

Knowing from FeelingKnowing from Feeling

Knowing from TastingKnowing from Tasting

Multi sensory KnowingMulti sensory Knowing

Knowing from rememberingKnowing from remembering

Knowing from askingKnowing from asking

Self Knowledge (First Person)Self Knowledge (First Person)

Others’ Knowledge (Third Person)Others’ Knowledge (Third Person)

Knowing Program: Sd’s 4-6Knowing Program: Sd’s 4-6Sd 4a: “Do I know what (label/attribute/feature/etc?”)

R 4a: “Yes/No”

Sd 4b: “Why?”/ “How do I know?”/ “Why Not?”

R 4b: “Because you can/can’t see/hear/smell/feel/taste it”/”

Sd 5a: “Does 3rd person know what (label/attribute/feature/etc?”)

R 5a: “Yes/No”

Sd 5b: “Why?”/ “How does he/she know?”/ “Why Not?”

R 5b: “Because 3rd person can/can’t see/hear/smell/feel/taste it”/”

Sd 6a: “Who Knows what (label/attribute/feature/etc?)”

R 6a: Child identifies appropriate person

Sd 6b: “How does person know?”

R 6b: “Because person can see/hear/smell/feel/taste it”/”

The CARD CurriculumThe CARD Curriculum

Language PlayTheory

ofMind

Social Skills

Social Skills

ExecutiveFunction

Self Help&

Motor Skills

School Skills

The CARD CurriculumThe CARD Curriculum

Choral ActivitiesChoral Activities Community Social Community Social

BehaviorBehavior Social PlaySocial Play Following RulesFollowing Rules SharingSharing TattlingTattling

Group DiscussionsGroup Discussions Levels of FriendshipLevels of Friendship Self EsteemSelf Esteem ApologizingApologizing Cooperative WorkCooperative Work Dealing with ConflictDealing with Conflict Safety AwarenessSafety Awareness Winning and LosingWinning and Losing

Social Skills

What skills are taught?

The CARD CurriculumThe CARD Curriculum

Levels of Friendship Child learns to identify Child learns to identify

the degree of the degree of relationship he relationship he experiences with people experiences with people in his environmentin his environment

Child learns to identify Child learns to identify and rehearse behaviors and rehearse behaviors that are appropriate to that are appropriate to each relationshipeach relationship

Social Skills

Sample Program

Strangers

AcquaintancesAcquaintances

Friends

Best FriendsBest Friends

The CARD CurriculumThe CARD Curriculum

Language PlayTheory

ofMind

Social Skills

Social Skills

ExecutiveFunction

Self Help&

Motor Skills

School Skills

The CARD CurriculumThe CARD Curriculum

Self-Help elf-Help • Eating & drinking

• Toileting

• Dressing

• Bathing

• Household Chores

Self Help&

Motor SkillsComponents

Fine Motor SkillsFine Motor Skills• Arm/hand/finger strength• Drawing• Cutting• Coloring• Writing

Gross motor skillsGross motor skills• Walking & running • Ball skills• Riding a bike

The CARD CurriculumThe CARD Curriculum

Language PlayTheory

ofMind

Social Skills

Social Skills

ExecutiveFunction

Self Help&

Motor Skills

School Skills

The CARD CurriculumThe CARD Curriculum

Processes that Processes that

underlie goal underlie goal directed behaviordirected behavior

Executive Function

What is Executive Function?

The CARD CurriculumThe CARD Curriculum

Visualizing situationVisualizing situation

Identifying desired Identifying desired objectiveobjective

Determining plan to Determining plan to meet objectivemeet objective

Monitoring progress Monitoring progress to goalto goal

Executive Function

Goal Directed Behavior Involves…

The CARD CurriculumThe CARD Curriculum

Executive Function

Self-Monitoring

FlexibilityPlanning &

Problem Solving

Working Memory

Attention

Inhibition

The CARD CurriculumThe CARD Curriculum

Language PlayTheory

ofMind

Social Skills

Social Skills

ExecutiveFunction

Self Help&

Motor Skills

School Skills

The CARD CurriculumThe CARD Curriculum

Math Addition & SubtractionAddition & Subtraction Advanced CountingAdvanced Counting Money Money Telling TimeTelling Time

Reading Comprehension Book TopographyBook Topography Story ComprehensionStory Comprehension Story SummarizingStory Summarizing Text ComprehensionText Comprehension

Spelling Copying and DictationCopying and Dictation RhymingRhyming

Vocabulary Synonyms and AntonymsSynonyms and Antonyms Thematic VocabularyThematic Vocabulary

School Skills

Scope

Joey’s Story: Joey’s Story: A Case StudyA Case Study

A case study: JoeyA case study: Joey

Joey was diagnosed with Autistic Disorder in December of 1995.

CARD Treatment was initiated in February of 1996 at the age of 3 years, 6 months.

Treatment intensity ranged from 30 to 40 hours per week of 1:1 in-home and school based behavioral intervention for approximately 2 ½ years

Deficits:Profound Delays in Joint AttentionMinimal Language Inability to Interact Socially with PeersNo Purposeful Concrete or Imaginative Play

   

Excesses:Frequent Non-compliance Frequent Tantrum BehaviorSelf-Stimulatory Behaviors: Lining objects, “video talk”, obsessions with trains, hand flapping and gazingEcholalia

Joey’s Repertoire at Intake:

Skills: One word

expressive labels Simple imitation One step receptive

instructions Some single word

responses to social questions

At Intake…At Intake…

Services: Year OneServices: Year One

Full inclusion in general education pre-school (12 hours p/w).

Full-time CARD shadow in the classroom. 25 hours per week home based behavioral

intervention.

Intervention: Year OneIntervention: Year One

Acquiring stimulus control of pre-existing behaviorsIncreasing compliance to requestsMandsIncreasing attending behaviorReducing maladaptive behaviorsObject labels (including names, animals, places)Actions / verbsAttributes (including colors)

Play Skills

Identifying emotions

Following instructions (increasing complexity)

Functions

Gender

Categories

Academic skills (Letters and Numbers)

Plurals, tenses, pronouns

At 3 Months…At 3 Months…

At 4 Months…At 4 Months…

At 5 months…At 5 months…

At 6 Months…At 6 Months…

Year-One Progress Chart: Year-One Progress Chart: Mastered Programs Mastered Programs

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Year-One Progress Chart: Year-One Progress Chart: Mastered Sub-skills Mastered Sub-skills

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Year-One Progress Chart: Year-One Progress Chart: Mastered ResponsesMastered Responses

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Services: Year TwoServices: Year Two

Full inclusion in general education preschool 20 hours per week.

Full-time CARD shadow in the classroom 25 hours per week of home based intervention

Intervention: Year TwoIntervention: Year Two

Intermediate Social Program Getting attention of

listener before talking Initiating play and

Joining a group Regulating volume of

speech Reading the body

language of others Sharing Turn taking

Responding to Emotions

Conversational skills

Pragmatic language skills

– Adjusting conversation according to audience

(perspective taking)

– Introducing a topic

– Staying on topic

– Providing sufficient information to listener

–Ending / closing conversation

At 12 Months…At 12 Months…

At 15 Months…At 15 Months…

Year-Two Progress Chart: Year-Two Progress Chart: Mastered Programs Mastered Programs

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Year-Two Progress Chart: Year-Two Progress Chart: Mastered Sub-skills Mastered Sub-skills

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Year-Two Progress Chart: Year-Two Progress Chart: Mastered ResponsesMastered Responses

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Services: Year ThreeServices: Year Three

Full inclusion in general education kindergarten Fading of full time “unknown” CARD shadow 10 hours per week of home based intervention

Remaining Deficits and Remaining Deficits and Excesses Excesses

Insufficient or irrelevant descriptions and explanations Inappropriate use of questions, initiations, topic

selection and conversations Inappropriate body language Avoidance of new people and places Inflexible, routine based play Frequent crying during social activities Difficulty entering a game in progress Inappropriate reactions to joking and playful teasing Deficient friendship development and friendship

maintenance behaviors

Intervention: Year ThreeIntervention: Year Three

Identifying simple intentions

Social cause and effect Knowing Think, feel, say, do Joking, teasing, lies and

deception

Topic selection

Topic introduction

Topic maintenance

Asking questions

Making statements

Play

Social outings

At 27 Months…At 27 Months…

Year-Three Progress Chart: Year-Three Progress Chart: Mastered ProgramsMastered Programs

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Year-Three Progress Chart: Year-Three Progress Chart: Mastered Sub-skillsMastered Sub-skills

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Year-Three Progress Chart: Year-Three Progress Chart: Mastered ResponsesMastered Responses

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Treatment GainsTreatment Gains

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6.0

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Ag

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Age 3.6 Age 4.1 Age 5.5 Age 7.7 Age 8.6

Vineland Adaptive Behavior Scale

Behavior Communication Daily Living Socialization

Treatment GainsTreatment Gains

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IQ

7 mths Tx 2 yrs Tx 1 yr Post-Tx

Wechsler Intelligence Quotients

PSIQVSIQFSIQ

At Discharge…At Discharge…In January of 1999, Joey no longer presented with any of the behavioral excesses or deficits observed at intake and services were terminated.

Joey’s original diagnosis was removed by an independent clinician from an outside agency.

Currently, Joey is fully mainstreamed and thriving academically and socially in a regular education second-grade placement. 

As reflected in the assessments, Joey not only made significant gains in all areas of adaptive and intellectual functioning, but continued to progress even 2 years post-treatment.

C.A.R.D.’s C.A.R.D.’s Preliminary Preliminary

Outcome DataOutcome Data

CARD Outcome StudyCARD Outcome StudyPurposePurpose

Examine the effectiveness of early Examine the effectiveness of early intensive ABAintensive ABA

Explore impact that intensity of 1Explore impact that intensity of 1stst year of year of treatment has on outcometreatment has on outcome

CARD Outcome StudyCARD Outcome Study

79 children participated79 children participated• 63 boys63 boys

• 16 girls16 girls

Average age at intake: 39.1 monthsAverage age at intake: 39.1 months Average IQ at intake: 76.8 (mild mental Average IQ at intake: 76.8 (mild mental

retardation)retardation) Length of time in tx: At least 3 yearsLength of time in tx: At least 3 years

(Children initiating program from 3/92-6/96)(Children initiating program from 3/92-6/96)

Overall Participant InformationOverall Participant Information

CARD Outcome StudyCARD Outcome Study

Of the 79 children participating:Of the 79 children participating:• 35 low intensity 35 low intensity

• 44 high intensity44 high intensity

The 2 groups were equivalent at intake in all The 2 groups were equivalent at intake in all areas examinedareas examined• AgeAge

• IQIQ

• LanguageLanguage

• Maladaptive BehaviorMaladaptive Behavior

• Adaptive BehaviorAdaptive Behavior

Participant Information:Participant Information: High & Low 1High & Low 1stst Yr. Intensity Groups Yr. Intensity Groups

CARD Outcome StudyCARD Outcome Study

Intervention: Hi Intensity Group: Received 26 or more

hours of CARD services (including school aide) per week.

Low Intensity Group: Received 25 or fewer hours of CARD services (including school aide) per week.

CARD Outcome StudyCARD Outcome Study

61%

20%

Mean Client IQ Pre- and Post-Treatment

70

75

80

85

90

95

100

1 2

IQ S

tan

dar

d S

core

High Intensity

Low Intensity

Pre-Treatment Post Treatment

CARD Outcome StudyCARD Outcome Study

61%

20%

Mean Adaptive Functioning Pre- and Post-Treatment

60

65

70

75

80

85

90

95

100

1 2

Vin

elan

d S

tan

dar

d S

core

High Intensity

Low Intensity

Pre-Treatment Post Treatment

CARD Outcome StudyCARD Outcome Study

0

10

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30

40

50

60

70

Per

cen

t

1 2

Normal IQ, Adaptive Fxn and Placement

25 hrs or less / wk 26+ hours / wk

61%

20%

CARD Outcome StudyCARD Outcome StudyFactors Associated with Positive Factors Associated with Positive

OutcomeOutcomeIntensity: 26+ Hours per week Intervention

Age at Intake: Treatment initiated prior to age 4

Parent Participation: Parents conduct therapy, attend clinics, read log book

Exposure to Typical Peers: When school is introduced, Regular Education is bestConcurrent Medical Management of Symptoms: Dietary changes & use of medsVerbal Imitation within the first 6 months of treatment

Dr. Doreen Granpeesheh

GPL Conference

CARD

QuestionsQuestions

Visual ModificationsVisual Modifications

Designed based on the childSome examples Picture Exchange Communication System

(PECS) for children with difficulty communicating vocally

Stimulus modifications for children with difficulty with auditory comprehension

Response modifications for children with difficulty with vocal output