Autism Spectrum Disorder (ASD)

• Autism spectrum disorder (ASD) is a neurodevelopmental disorder evident in early childhood.
• Standard classification systems previously included:
  • Autistic disorder
  • Asperger's disorder
  • Rett's disorder
  • Childhood disintegrative disorder
  • Pervasive developmental disorder not otherwise specified
• Clinicians diagnose ASD based on criteria from the DSM-5.
• The DSM-5 no longer includes differential diagnoses like Asperger's or pervasive developmental disorder not otherwise specified.
• ASD is characterized by two core impairment areas
  • Impairment in reciprocal social communication and social interaction
  • Abnormalities in behavior patterns, characterized by restricted, repetitive, or stereotyped interests or activities.
• Difficulties in social communication include
  • Social and emotional reciprocity
  • Reduced affect
  • Unresponsiveness to social interactions
  • Odd and repetitive speech patterns
  • Delayed speech and language skills
  • Complete lack of spoken language
• Individuals with ASD may have difficulties with eye contact, peer relationships, and play skills.
• Abnormal behavior patterns consist of
  • Repetitive behavior
  • Stereotyped body movements
  • Restricted activities
  • Resistance to environmental changes
• Individuals may display hyper- or hyporeactivity to sensory stimulation.
• Clinicians specify ASD severity at three levels:
  • Level 1: Requiring support
  • Level 2: Requiring substantial support
  • Level 3: Requiring very substantial support
• Severity is based on impairment in social communication/interaction and restricted, repetitive behaviors.
• Over the past 30 years, the prevalence of ASD has increased.
• Recent estimates indicate that ASD occurs in 1 in 54 children.

Associated Features of ASD

• Several medical conditions and behavioral excesses/deficits correlate with ASD.
• Associated features are not part of ASD diagnostic criteria.
• Include sleeping and feeding disorders, delays in toilet training, severe behavior problems, and genetic and medical conditions.

Sleep Problems

• Individuals with ASD display a higher incidence of sleep problems, including
  • Increased daytime sleep
  • Decreased total sleep
  • Bedtime tantrums
  • Frequent night wakings
• Sleep problems can cause:
  • Decreased cognitive functioning
  • Increased self-injurious and severe problem behavior
  • Increased parental stress

Feeding Disorders

• Individuals diagnosed with ASD have substantially higher feeding disorders than typically developing children
• Up to 90% display inappropriate mealtime behavior.
• Common feeding problem: food selectivity, perhaps due to rigid and restricted interests.
• Children may not meet daily nutritional needs due to limited consumption of foods high in macro- and micronutrients.
• ABA-based treatments prove effective in increasing the variety of foods consumed and decreasing inappropriate mealtime behavior.

Delayed Toilet Training

• Many developmentally disabled individuals do not finish toilet training before age 6.
• Over half of parents with ASD children report concerns regarding toilet training and incontinence.
• Azrin and Foxx (1971) created an intensive behavioral treatment package for adults with developmental disabilities, including:
• Reinforcement for voids on the toilet, fluid loading
• Scheduled toilet trips
• Overcorrection
• Variations of this package have been evaluated in studies

Severe Problem Behavior

• Individuals are likely to engage in
  • Self-injurious
  • Aggressive
  • Disruptive behavior
  • Noncompliance
  • Elopement
  • Pica
• Researchers identify environmental variables that maintain problem behavior using functional-analysis procedures.
• Results inform treatment.

Associated Conditions and Genetic Disorders

• Individuals may have some level of intellectual impairment; estimates range from 18% to 70%.
• Medical conditions and genetic syndromes are more common.
• About 16% are diagnosed with epilepsy, with onset during childhood or adolescence.
• Genetic disorders, including tuberous sclerosis and fragile X syndrome, are also associated with ASD.

EARLY INTENSIVE BEHAVIORAL INTERVENTION

• EIBI is a comprehensive treatment approach for children
• Includes a comprehensive, hierarchically arranged curriculum implemented for several years
• Goal is to improve a child's overall functioning
• Procedures are developed based on operant conditioning principles, such as:
  • Reinforcement
  • Stimulus control
  • Generalization
• Designed to increase adaptive behavior and reduce problem behavior
• EIBI therapist provides learning opportunities using programmed instructional and reinforcement procedures.
• Program targets multiple functions in a developmental sequence, improving broad skill areas.
• Educational targets include:
  • Preacademic and academic skills
  • Verbal behavior
  • Social skills
  • Independent-play skills
• EIBI programs last 2-3 years for 25-40 hours per week
• Includes individualized instruction in settings such as home, community and school
• Surveys show EIBI is one of the most common and requested treatments

UCLA Young Autism Project

• Landmark outcome study that documented improvements in about 47% of children receiving EIBI.
• Gains in functioning were maintained into adolescence.
• Success led to additional research and dissemination.
• EIBI is the most studied comprehensive treatment model for young children.
• Research compares
  • Different intensities of EIBI
  • EIBI and other treatments
  • Clinic- versus caregiver-managed models
• Researchers have established criteria to review empirical support for EIBI in experimental studies (experimental rigor, verification of diagnosis, and measures of procedural integrity).
• Meta-analyses have sought to identify variables predicting behavioral intervention outcomes.
• Research on IQ at the start of treatment and whether the child benefits from EIBI has produced mixed or negligible results.
• EIBI programs with better outcomes (higher IQ scores, improved adaptive behavior, increased language skills) include:
  • Greater treatment intensity
  • Longer treatment duration
  • Caregiver training
  • Supervisor training with the UCLA model
• Results of meta-analyses and systematic reviews show EIBI is effective for many behavioral deficits and excesses
• National Standards Project identified it as an "established intervention"
• An established intervention has enough evidence to permit determination that the intervention produces positive outcomes
• EIBI has the most empirical support of all comprehensive treatment models.

ABA-Based Models of Early Intervention

• Developed to improve outcomes for children
• Models below have demonstrated effectiveness in studies and authors have published treatment manuals- review each model and describe key differences- and recommendations to improve learning

Natural Environment Training

• Emphasis on child-directed interactions
• Techniques that increase motivation to respond
• Generalization of skills
• Conducted in settings such as home, with caregivers trained to promote learning opportunities during playtime
• Capitalizes on naturally occurring establishing operations to teach functional-language skills
• Incorporates choice-making opportunities, frequent preference assessments
• Reinforcer variation across trials
• Intersperses mastered tasks to maintain motivation
• Programs training in free-play-like settings
• Decreases the similarity between the training setting and typical academic settings
• Typically targets requests for items in the initial portion of treatment to establish a functional relation between the vocal response and associated reinforcers
• Recommendations made by Stokes and Baer (1977) to promote training
• Training multiple exemplars
• Training across settings and therapists.
• Using intermittent contingencies generalization

Incidental Teaching

• Developed from experiences teaching language to preschool children in natural settings
• Conducted in unstructured settings such as free-play time
• Child-directed
• A therapist uses a child's initiation as a learning opportunity
• Teaches child to respond to multiple cues in the natural environment with spontaneous language
• Programs incorporate discriminative stimuli that signal the availability of adult attention for language attempts
• Therapist initiates learning trial when child shows interest in an item by pointing or gesturing to it.
• The therapist physically approaches the child
• Engages in eye contact
• Exhibits a questioning look
• Prompts if the child does not emit a spontaneous vocalization
• Fades prompts as the child responds accurately after less intrusive prompts
• Recommends rotating among a few prompts that are context-specific
• Limiting prompt variety ensures that the prompt functions as a discriminative stimulus for the vocal response.
• Previous research showed:
  • Effectiveness in producing variability in verbal responses
  • Generalization to novel therapists
  • Preference for play activities that incorporated incidental teaching
• Research on children with ASD indicated:
  • Training produces generalization of language
• McGee, Krantz, and McClannahan (1985)
• Compared incidental-teaching and traditional-teaching procedures
• Noted the acquisition of target prepositions did not vary across teaching procedures
• Incidental-teaching sessions were longer than traditional-teaching sessions
• Conclusion: need additional research comparing teaching to identify procedures that produce:
  • Rapid acquisition
  • Levels of attending
  • Generalization of skills across settings and therapists
  • The least amount of instructional time necessary to produce mastery of target skills
• Additional need to identify child preferences for language-training strategies

Natural Language Paradigm

• Developed as both training and play, to create learning
• Provides child with choices between high-preference stimuli
• Learning Begins- child selects a preferred item
• Access is restricted, models short phrase, motor activity, uses shaping reinforce closer approximations across trials.
• Provides short access to the preferred item & pair it with Reinforcement & play
• Repeat the vocalization during reinforcement
• Removes item, models diff. phrases
• Repeats initial steps
• Goal to prevent and maintain response driving force
• Uses graduated delay to spur on spontaneous language
• Training- involves repeating rounds toy sharing,
• Facilitates expansion- multiple replies stimuli
• Research on the natural language paradigm shows skills speed & expansion across different arenas

Pivotal-Response Training

• Focuses on pivotal areas: skills that boost improvement in other areas.
• Intervention transpires naturally- child's house etc
• Exploits naturally arriving environmental stimulus such model vocally and actioning when child mirrors
• Promotes Care givers & educators to adopt across different settings for training

Applied-Verbal Behavior

• The applied-verbal behavior approach to early intervention for ASD is based on Skinner's (1957) functional approach to verbal behavior.
• Functional approach defines a verbal operant based on:
  • Topographical characteristics
  • Antecedent events
  • Consequent events
• Skinner's (1957) taxonomy includes seven elementary verbal operants
• Early intervention programs typically focus on five of these:
  • Mand
  • Tact
  • Echoic
  • Intraverbal
  • Autoclitic
• Treatment typically begins with mand training for benefit to the speaker
• A mand is a verbal operant that a relevant establishing operation evokes the delivery and requested consequence reinforces
• Behavior analysts should conduct mand training by using the appropriate antecedent and consequent events.
• Effective when:
  • Relevant establishing operations are present or presumed to be present
  • Consequence related to the child's mand is available

Discrete-Trial Training

• Developed behavioral means children ASD
• High structured methodology table to educate, parts to teach etc. Each segments mastered then merged in behavior order
• Top selections supplied upon good answers
• Quick skill getting because it permits more trials & opportunities

Unique Features of Early-Intervention Models

• All behavioral based versions adopt techniques
• Both emphasize naturalistic education requests & conditions where childs keen to obtain the item
• Skills differ from training
• Requires explicit, verbal stimuli e.g what it's called as opposed conditioning with trials under management, natural etc

Combining Early-Intervention Models

• Each model brings unique strength for treatment
• Therapist might mix techniques to aid function, stimuli etc with training

CLINICAL CONSIDERATIONS AND FUTURE RESEARCH

• Reinforcement and the setting and climate are great key in impacting effectiveness
• Analysts do various tests identify hierarchy reinforcing for each candidate
• Intersperse the opportunity & support selecting

Assessing and Identifying Target Skills

• Behavior analyst must analyze candidates present ability stage, several areas, choose the stage to enter & improve
• The formal evaluations support measuring conduct etc at the start & during the whole teaching process

Instructional Procedures

• Better improving on methodologies and success especially tailored those with ASD/learning
• The use checks in place give the best, greatest benefit

Identifying Effective Prompting Strategies

• Check, then promote the individual
• The use and the setting

Maintenance and Generalization

• Prime motive is child demonstrating before taught in setting, conditions etc
• In circumstances models miss generalising or support

Treatment Integrity

• Numerous trials show positive connection
• A few show various elements hurt progress and overall outcomes