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Today, we are going to be broadly talking about what interventions
are available for treating symptoms of an autism spectrum disorder.
These are interventions that are generally described as having
some evidence base within the general population,
and we'll talk about what considerations might be for autism intervention
specifically with children, who are deaf and hard of hearing.
But my hope today is to give the audience an understanding of interventions
that were specifically developed for autism,
many of which show promise for being modified for use with children,
who are deaf and hard of hearing.
In a future broadcast, we'll be talking more specifically at educational interventions
for children, who are deaf and hard of hearing with an autism spectrum disorder.
But our goal today is to provide a more broad-based understanding
of what autism intervention in a comprehensive sense can look like.
The reason I'm talking about autism intervention,
not just autism intervention as it happens in the school environment,
is that according to the National Research Council, in 2001
they published guidelines called, "Educating Children with Autism",
and those guidelines indicate that autism intervention should begin
as soon as autism is suspected, not even just after the diagnosis is received.
not even just after the diagnosis is received.
Because we know, especially for kids, who are deaf and hard of hearing .
that sometimes that diagnosis is prolonged,
but that the intervention should also be
of a certain amount of intensity to show impact.
The guidelines indicate that autism intervention should be
a minimum of 20 to 25 hours per week
of autism specific intervention.
Now, I want to be clear about this. This does not mean that the child has to have
20 to 25 hours a week one-on-one with an interventionist.
The guidelines are intended to encapsulate the intervention that the child receives
at school, as well as interventions that they receive from private providers,
as well as the interventions that families are doing taking all the strategies
that they've learned from, that work well for their child with autism at home.
What's intended here is for there to be a very comprehensive, multi-tiered intensity
around intervention from both school providers,
as well as in the home and from community-based providers.
It's helpful for individuals in schools to know what these other interventions are,
so that you can work collaboratively with the child's other providers.
My intention today is to outline what some of those interventions are so that
everybody has an understanding of what's available for autism intervention,
and so that you can work and have a shared language
around providers outside of the school setting.
The guidelines also indicate that interventions
should be individualized.
Because children with autism
have certain core symptoms,
many of which present differently from child to child,
it's really important that the intervention
not just be a packaged intervention,
but that it be one that's tailored
to the unique needs of the child.
That it be systematic.
That there's a plan and an intention around that intervention programming,
and that it is developmentally appropriate.
The interventions that are appropriate for older children are likely to look
quite a bit different than the interventions for younger children.
It's important that intervention target the core symptoms
that we know are associated with an autism spectrum disorder,
communication, social communication across a variety of different settings.
There are cognitive development, play skills,
and proactively addressing challenging behaviors.
It's important that the intervention have a piece of collaboration
with highly trained professionals, who have some understanding
of an autism spectrum disorder and autism intervention.
This is going to require quite a bit of collaboration especially for kids,
who are deaf and hard of hearing, who also have an autism spectrum disorder.
Collaborating between professionals, who know and understand the deafness
and between providers, who understand autism and autism intervention.
In most places in the country, unfortunately, there are few providers who know both,
so that collaborative piece is really important.
The good news is that what we know is that the evidence
is starting to show us that this systematic intensity
around intervention can change the course of those core deficits,
and those core difficulties associated with autism.
We're still learning about who benefits most from what type of intervention,
and there's a long way to go in that regard,
but it's positive to know that a lot of kids benefit from these types of interventions.
One of the things that's really important to know about intervention for autism
is that there's no medication that's been demonstrated
to have an impact on those core symptoms of autism
in terms of the social difficulties, the social communication deficits,
and the repetitive behaviors and restricted interests.
Medications are sometimes used to address some of the associated difficulties
like sleep difficulties, gastrointestinal symptoms, seizures,
and some behavioral difficulties, but the medications have not at this point
been demonstrated to be effective in addressing those core symptoms.
The other thing that's important to know is that there are many different interventions
that have shown some promise in terms of effectiveness.
What works for one child may not necessarily work for another.
But there are some that have shown to have more of an evidence-based practice
than others. What's important is that you think through the intervention.
What are the symptoms that you're trying to be addressed?
And making sure that you select the intervention that's tailored to address
those specific areas of difficulty.
As a result, we're starting to see
with this highly individualized systematic interventions,
starting to see changes in terms of higher cognitive skills among individuals,
who have received autism intervention: better language skills,
improve social skills, and families are less stressed and happier,
if their child is receiving the supports that they need.
These are results that have been demonstrated
with hearing children with an autism spectrum disorder.
We have no reason to think that if we're able to provide
effective interventions for kids who are deaf and hard of hearing,
I would assume the same outcomes for them,
until somebody shows me evidence to the contrary.
The good news is we've moved away from things like IQ
as an outcome measure of showing whether an intervention
is working or not because for families and for individuals
whether or not a child's IQ was increased as a result of intervention,
didn't necessarily play out in terms of what was important
for the quality of life for that child. So we're starting to look more towards
are we seeing improvements in those core difficulties of autism:
their eye contact, their social communication, their ability to have
and sustained friendships, and also what's their quality of life?
Is the individual demonstrating a quality of life that's satisfying to them?
Are they able to seek and obtain and hold a job?
Those kinds of things.
In thinking about what interventions that we're selecting for kids
with an autism spectrum disorder, we need to think about what's the long-term goal,
and outcome that we're looking at and make sure that we're selecting
an intervention that's going to help us reach that goal.
I'm going to describe several different types of interventions
that have been shown to have some degree of effectiveness with hearing children
with an autism spectrum disorder. Again with a goal to make you all aware
that these interventions are available and to think through
how they may be applied for children, who are deaf and hard of hearing.
Many of you may have students in your class, who are getting outside intervention,
and knowing what that intervention is targeting, could be helpful
in using some of the same strategies in your classroom or in your home.
Again the interventions that I'm going to be discussing
each has a different theoretical approach and targets very specific behaviors
and symptoms of autism. You need to make sure that you're thinking
about why you're selecting an intervention before you choose one.
Again you want to make sure that you're selecting an intervention that targets
the symptom of autism that's relevant to the child
and that's appropriate for the child's level of development
to increase your likelihood that the intervention will be effective.
Please refer to the links in the description of the video below for information
about resources, where you can see information about the interventions,
that I'll be describing and where you can see videos,
that show some clips of the interventions.
The first one that I'll refer you to is
the National Professional Development Center on Autism Spectrum Disorders.
This is a site that reviews evidence-based practices in autism.
That's helpful to make sure that you're selecting an intervention,
that shows some evidence-based promise.
The next reference is from the Autism Speaks website,
and in their website they provide a description that's more comprehensive
about the interventions, that I'm describing here.
In some cases, they also have videos where you can see clips of the intervention
so that you can compare what they look like.
Again these are resources for children, who are hearing, who don't necessarily have
reduced hearing, but ideally you'll be able to think through
applying the interventions to kids who are deaf and hard of hearing.
Probably the most commonly sited intervention, and the one that shows
the strongest evidence-based effectiveness for treating symptoms
of autism is something called Applied Behavioral Analysis,
or you might have heard that before as ABA.
ABA is a way to apply the concepts that we know about learning and motivation,
that stems from behavior analysis, to teach proactively positive skills.
In this case the skills, that we're talking about, are those social communication skills
and positive behavioral skills. The idea is to consider what is the behavior that
you're trying to see increase. For example, in treating an autism spectrum disorder
that might be increasing eye contact, or increasing the amount
of the frequency with which the child initiates play with peers,
or their ability to take turns in a conversation.
ABA does a very good job of encouraging individuals to explicitly identify
what is the behavior, that you're trying to increase,
and then to think through what happens before and after
that behavior to make it more likely that you'll see those positive behaviors.
An example that would be, in teaching eye contact.
I might change what happens before I asked for eye contact from the child
by getting down at the child's level, so I've changed the antecedent. Right?
To make it more likely that I'm going to get eye contact from the child.
And then I might get down low and say, "Look", or "Johnny" or make a fun noise,
and when I get eye contact, I might give the child the toy.
That's the consequence, the reinforcing, the act of looking.
The behavior that I was targeting.
That's a simplistic way of talking about what ABA looks like,
but usually when you work with somebody, who's practicing ABA
they'll identify several different goals that you'll work on in a very systematic manner.
ABA also is helpful in addressing problematic behaviors.
It works in targeting positive behaviors, that you want to see increase,
as well as, using similar principles to decrease those challenging behaviors.
Challenging behaviors in autism might be anything from self injurious behavior,
where a child is hitting themselves or biting themselves,
to outbursts in the classroom.
You would use these principles to address those behaviors.
This can take many different forms.
In the early studies, we talked a lot about something called Discrete Trial Training.
Some of you may have heard of the Lovaas Technique,
where this was done in a highly structured manner.
Where you might say, "Johnny, smile", and when Johnny smiled, you reinforced that
with an external reinforcer, like a piece of candy.
There are other models of ABA or the interventions
that we'll talk about today incorporate aspects of ABA
and integrate it in a way that focuses more on generalizing behaviors
across different settings into different providers.
Again, ABA is something that was developed for use with children, who are hearing,
but the principles of ABA are certainly things that can be applied to children,
who are deaf and hard of hearing.
One of the approaches, that's commonly talked about in and used in schools
is often referred to as the TEACCH Approach.
This actually is called the Perceptual Cognitive Approach,
because the model was based on the idea that children with autism have differences
with their cognition, and their perceptual and sensory systems.
TEACCH really addresses those aspects of trying to make
the classroom environment or the home environment
something that the child with autism can understand.
It builds in lots of organization, lots of structure, lots of routines,
a lot of visual supports, so that it provides the infrastructure
to help the child, who has autism, be able to participate and manage
the cognitive of aspects of the tasks that are challenging for them.
In the description of this video, you'll see links to a video
that will show you some of the different aspects
of the TEACCH model, and what they can look like in the classroom.
Many of you might be familiar with things like entering a classroom,
that uses TEACCH principles, that has study carrels
or very specific workstations that comes from the TEACCH model or work-baskets,
so that the child knows, what they have to do, and when it's finished,
if the work is completed in the work-basket,
that's a very concrete way of letting the child with autism know,
that the task is completed, which is very important for children with autism.
You'll see some links to videos in the description of this video,
that give you examples of what this model looks like.
I'm going to talk now about several models of autism intervention,
many of which also incorporate aspects of ABA, that we've already talked about,
and even some which incorporate aspects of that TEACCH model.
The unifying aspect of these models is
that they're considered developmental models,
because they emphasize intervention that takes place in the child's natural settings
as opposed to a clinic space, where they use materials that are commonly available
to the child in their home and in their school environments, that the models
emphasize interaction versus the child just being able to do something
in isolation and again many of them incorporate those aspects of ABA,
like systematically thinking through reinforcement for the child.
Another aspect that's true of these models is that they capitalize
on the child's interest. First, starting from a place where you can recognize
what the child is interested in and using that as an opportunity
to build on learning very specific skills related
to the areas of difficulty that they have.
For example, this might be if you notice that a child is really drawn to musical toys.
Using music with their parents and teachers to teach them attending skills
or staying in circle time and using the reinforcing and motivating nature
of those activities and interests to make it more likely that the child
will be engaged in learning these new skills.
Another thing that these developmental models have in common
is the use of something called High Affect.
By high affect, I mean using a lot of your intonation, your body language,
your kind of spirited affect to try to hook and catch the child's attention.
Children with autism have been shown to not necessarily attend to faces
the way that typically developing children do, but what the research has shown
is that, if we bring up the affect and the energy level, it can mark yourself
as something that stands apart from every other face
and every other individual and capture the child's interest and their attention.
One of these models is called Pivotal Response Treatment or PRT.
This was developed by Dr. Robert Koegel and Dr. Lynn Koegel.
It's a play based model, which was a change
from some of the earlier autism intervention models,
It also is a change, because it's child driven.
The idea is again to start with what the child is showing you
that they're interested in and using that to build communication skills,
positive social behaviors, and to address any negative self-stimulatory behaviors,
that the child has. Pivotal Response Treatment is based
on the principles, that there are certain areas of development that are really critical,
that serve as a foundation for building every other skill.
For the developers of this model,
those include: making sure that you've captured the child's motivation,
making sure that the child is able to be self-regulated,
making sure that the child is able to initiate social interactions
and making sure that they're able to respond to multiple cues
in different aspects of their environment.
Unlike some of the earlier ABA models, that use external reinforcers,
like giving a child a token or a piece of candy,
when they demonstrated a positive skill like eye contact or saying a word,
the developers of this model really emphasize natural reinforcement,
instead of reinforcing a child with a piece of candy if they said "Car",
in Pivotal Response Treatment, you might find something that the child likes,
like cars. Using that thing that's intrinsically motivating to them,
setting up a play opportunity with the child and maybe withholding the car
until they make an approximation like "/k/"or say "Car" or sign "Car"
and then giving them the car, so giving them that natural reinforcement,
through your affect, as well as, the object that they're requesting,
as opposed to some unrelated reinforcer, like a piece of candy.
One of the models that's been developed for young children
with an autism spectrum disorder that has shown a lot of evidence-based promise.
It's called Early Start Denver Model.
This was developed by Sally Rogers and Geraldine Dawson and their colleagues.
It's called Early Start Denver Model, because it actually started here in Colorado
as the Denver Model and then was expanded upon and modified.
This is an approach that's appropriate for young children with autism,
who are ages 12 to 48 months. This is a developmental model,
so again it takes into account those aspects of what's motivating
to the child, natural reinforcers, and happens in naturalistic settings,
like the child's home, and also integrates ABA principles.
What's nice about this model is that it's very comprehensive
and developmentally focused. It's based on the idea that children,
who have autism, often have splintered developmental skills
and if we don't address those areas that they haven't yet acquired
that it makes it more difficult for them
to acquire later developmental skills and move forward.
So whereas some of the models might emphasize just on the development
of language skills, this one emphasizes language, fine motor skills,
gross motor skills, play skills, and all the aspects that we know
can be challenging for children with autism
like an imitation, turn-taking, those kinds of skills.
In the resource guide at the end of this presentation,
you'll also see some references for this particular model.
One of them an Early Start for Your Child with Autism
is a really nice parent manual that teaches how do we build social routines
for a child within the context of our lives.
It's very practical, very easy to understand and really relays
the concepts of the model in a very family-friendly manner.
You'll also see links to videos where you can see what this intervention looks like.
This is an intervention that is being applied clinically with young children,
who have reduced hearing. We just don't have the research yet
to know how to best modify the model for children
especially for children, who communicate using a sign language.
But the principles of the model are certainly applicable
and in a case study basis have shown some promise
for use with young children, who are deaf and hard of hearing.
I want to touch very quickly, so that you are aware of these interventions.
There's another intervention targeting young children with autism spectrum disorders
called LEAP, which is short for an acronym,
for Learning Experiences and Alternative Program for Preschoolers and Their Parents.
This is another model that actually comes out of Colorado,
and it's a preschool based curriculum, where the teachers are trained
how to work on things like peer mediated social skills, encouraging children
to help reinforce the child with autism in their social skill development.
It includes, how do we capitalize on incidental teaching moments?
It also includes, how do we support behavior in the classroom?
This is a nice model to look at if you're looking for an educational model
for young children with autism.
Another educational model that has been developed by
Barry Prizant, Amy Wetherby, Emily Rubin and Amy Laurant
is called the SCERTS Model,
which is an acronym for the aspects or the symptoms of autism
that this model really targets
which is social communication that's the "SC",
emotional regulation which is the "ER",
and transactional supports for children and older individuals
with autism spectrum disorders.
This is a model that can be applied across the age span.
It is a very interdisciplinary approach, where the intention
is to complete an evaluation about the child's needs
from an interdisciplinary perspective and then to implement supports
across disciplines within the school settings to help target
those very specific aspects that we know can be challenging
for children with autism.
The resource guide at the end of this presentation will also include
a link to resources on this model.
Now I'd like to shift a little and talk about some interventions to specifically target
the speech and language skills of children with autism.
In the literature of autism intervention for children, who are deaf and hard of hearing,
there are very few articles that are available that have looked at this.
One of the few out there is one that has looked at using this strategy
of an intervention called Picture Exchange Communication System or PECS
to build language skills for a child, who's deaf who also has autism.
This particular intervention was based on very operant condition based philosophies
about how language is acquired and uses visuals like the picture that you see here.
to teach a child systematically how to initiate communication with others.
Initially the child might take the picture that represents the thing
that they want. It's the next level of abstraction.
To give the card in place of a spoken word or a sign,
to give the card to an adult or another peer in exchange for the thing
that they really want. That's the first step of this.
This was intended to be used with children who are not being successful
initially with either using spoken language or sign language
as an abstract means of representing what they really want.
The visual card makes that much more concrete and ideally
would make it more obvious to the child
to be able to use that to communicate with others.
That then gets reinforced by the person who's receiving the card
by giving them what they asked for. Then the child is starting to learn to recognize,
"Oh, communicating with other people has value."
So using the cards to build that motivation for engaging with other individuals
in their environment. The PECS strategy is very systematic and the resource guide,
it'll explain what the different stages are of using this as a strategy
to build more and more language use. You start first at the single word level
with perhaps very concrete pictures of the objects that the child is requesting,
and use it primarily for requesting and then you build upon that to communicate,
not just requests, but also commenting and also sharing information,
and then going also beyond the single word level
to using those pictures to communicate increasingly complex grammatical features,
like using sentences like, "I want," and then ball or "I want," and then snack.