Early Intervention in Autism DR . PRADEEP DUBEY MD. (Ped.) DCH Aadiguru Neuropediatric Centre, Near Prem Mandir Wright Town, Jabalpur

Autism and Childhood Schizophrenia Once thought to be a form of schizophrenia Differs from schizophrenia in terms of symptoms, age of onset, family history, etiology, and response to treatment

Definition of Autism markedly abnormal or impaired development in: social interaction communication and markedly restricted repertoire of activities and interests.

Definition of Autism (continued) Definitions are cheap, but explanations are dear, and we must be careful not to confuse them. David Palmer, 2004

Autism Spectrum Disorders Neurological disorders characterized by "severe and pervasive impairment in several areas of development Autistic Disorder Asperger's Disorder Childhood Disintegrative Disorder (CDD) Rett's Disorder PDD-Not Otherwise Specified (PDD-NOS)

Prevalence of Autism Typically diagnosed within first three years 2 to 6 in 1,000 individuals (Centers for Disease Control and Prevention, 2001) Four times more prevalent in boys than girls

NIH Research Dollars Devoted to Autism When compared with other serious childhood conditions, autism is much more common, but fewer dollars per case are spent on autism.

Prevalence of Autism and Other Conditions (Number of Cases per 10,000 Children) 70 60 50 40 30 20 Autism is a debilitating disorder that affects 1 in 166 children. It is 10 times more common than juvenile diabetes, muscular dystrophy, childhood leukemia, and cystic fibrosis combined, yet over 100 times more research dollars per case are spent on these other conditions than are spent on autism. Awareness of the need to increase funding for both basic and applied research on autism is rapidly growing in both the public and private sectors. We are at a unique juncture, …a point in time that provides a rare opportunity to realize our vision of developing one of the premier centers of excellence in the study and treatment of autism. We have ongoing collaboration with colleagues at major medical centers like Johns Hopkins and Emory University, and we are developing new area of collaboration with experts at Boston University, and the Universities of North and South Dakota. Our strategy is to build upon our current strengths and to add key areas of expertise that will complement one another and create a heightened level of synergy and innovation. 10 Autism Juvenile Diabetes Muscular Dystrophy Leukemia Cystic Fibrosis

NIH Research Dollars for Autism and Other Conditions (Number of Dollars per Case) $140,000 $120,000 $100,000 $80,000 $60,000 Before discussing operant mechanisms that may be directly relevant to the diagnosis of autism, I will first briefly describe how functional analysis methods have recently been extended to the examination of complex relations involving multiple operant mechanisms. READ SLIDE. $40,000 $20,000 $- Autism Juvenile Diabetes Muscular Dystrophy Leukemia Cystic Fibrosis

Demographics of Autism Knows no racial, ethnic, or social boundaries Family income, lifestyle, and educational levels do not affect the chance of autism's occurrence Diagnosis of autism is growing at a rate of 10-17% per year (U.S. Department of Education, 2002)

Assessment and Diagnosis of Autism No medical tests for diagnosing autism Accurate diagnosis is based on observation of the individual's communication, behavior, and developmental levels. Autism Diagnostic Interview-R (ADI-R) Home and/or school observation Video analysis of behavioral observation

Identifying the Genetic Bases of Autism Spectrum Disorders Etiologic workups identify specific genetic causes for autism in about 20% of cases. At the Munroe-Meyer Institute, Dr. Schaefer and colleagues (2006) developed a 3-Tiered Approach that identifies genetic causes in 40% of cases. We are already a leader in genetic diagnosis among children with autism. Most centers are able to identify a specific genetic cause for autism in only about 20% of cases. Our experts at the Munroe Meyer Institute have doubled that figure and continue to make further advances.

Early Screening for Autism (NICHD) Does not babble or coo by 12 months Does not gesture (point, wave, grasp) by 12 months Does not say single words by 16 months Does not say two-word phrases on his or her own by 24 months Has any loss of any language or social skill at any age

Early Screening for Autism (CHAT) Does not display pretend play (e.g., pretending to drink from a toy cup) Does not point at objects to indicate interest Does not show interest in other children Does not enjoy peek-a-boo hide-and-seek or other social games Does not bring and show objects to parents

Associated Disorders Mental Retardation 70% 15% Autism ASD Mental Retardation 70% 15% Seizure Disorder 35% 10% Self-Injury, Aggression 50% Tourette Disorder Bipolar Disorder

Associated Etiologic Diagnoses Fragile-X syndrome Tuberous Sclerosis Williams syndrome Landau-Kleffner syndrome Congenital Rubella Smith-Magenis syndrome Neurofibromatosis

Genetics and Twin Studies Autism runs in families Heritability for autism is about 90% Monozygotic twin concordance, 60%-100% Dizygotic twin concordance, 10% Associated with abnormalities on chromosomes 7q, 2q, and 15q

Applied Behavior Analysis (ABA) What is ABA? How is it different from other approaches? How is it done?

Baer, Wolf, & Risley (1968) APPLIED—strives to produce rapid and clear benefit to problems of social importance; BEHAVIORAL—uses objective and accurate measurement of the behavior of interest; ANALYSIS—uses controlled (single-case) methods to understand the environmental variable(s) that influence an individual’s behavior.

Historical Roots of Behavior Analysis 1911 Thorndike-Law of effect 1924 Watson-Behaviorism 1927 Pavlov-Conditioned Reflexes 1938-Skinner Behavior of Organisms 1950’s-Behavioral applications reported in scientific journals 1968-Journal of Applied Behavior Analysis

How Effective is ABA for Autism? About 50% of Children with autism and mild mental retardation who received early intervention with ABA attain normal IQs and are educated in regular classrooms with minimal assistance.

Outcomes of ABA for Autism 35 30 25 20 Increases in IQ Scores 15 r = .79 p < .02 10 To date, ten peer-reviewed studies have reported reported clinically significant improvements in IQ following intensive early behavioral intervention. There has been considerable variation across studies with regard to the specific behavioral components included in these studies and also in the amount of treatment provided. Nevertheless, across these studies, the median IQ gain was about 20 points.. Not quite as large as those reported by Lovaas, but still impressive. In addition, the general trend across studies is that the number of hours of treatment per week is significantly correlated with gains in IQ scores. 5 5 10 15 20 25 30 35 40 45 Hours per Week of Treatment

How Effective is ABA for Autism? Early Intervention of Autism using ABA has been recommended by: New York State Dept. of Health U.S. Surgeon General National Research Council Association for Science in Autism Treatment

Why is ABA Effective? ABA developed from and remains closely linked to basic research on the principles of learning and behavior. A central principle of ABA is called “Selection by Consequences.” In a given environment, behaviors that produce favorable outcomes are selected (or continue to occur) and those that produce unfavorable consequences are extinguished.

Why is ABA Effective? (continued) ABA has developed a wide variety of procedures for identifying the antecedents and consequences that influence behavior. We rearrange the antecedents and consequences in the environment so that appropriate behavior is selected (or re-occurs) and problem behavior is extinguished.

Why is ABA Effective? (continued) Specific procedures include Shaping Chaining Prompting Fading Extinction Reinforcement Generalization strategies, etc.

Why is ABA Effective with Autism? Comprehensive: Teaches all skills (e.g., sitting, attending, imitating, direction following, language, social skills, self-help skills). Goal and Data Driven: The focus on objective measurement and analysis of behavior provides ongoing feedback on progress and setbacks.

Example of Individual Goals for Billy Decease self-injurious behavior Increase eye contact Increase spontaneous requesting Increase labeling skills Increase use of yes and no Increase imitation skills Increase matching skills Increase letter identification Increase self-feeding skills Billy is a 3-year-old male diagnosed with autism. Billy receives 30-40 hours of therapy using Applied Behavior Analysis (ABA). Prior to treatment implementation the following goals were developed. The following goals are addressed multiple times a day. Data are collected on all goals prior to the implementation of treatment. Progress is assessed on a daily basis.

Teaching Imitation Using Discrete Trials Starts with simple responses (e.g., clapping). Sessions consisting of 10 trials; each trial starts with the therapist saying “Do this” and then modeling the target response. Any approximation of clapping, results in delivery of a preferred reinforcer (e.g., toy). Otherwise, the therapist guides the child’s hands to complete the response and then begins the next trial.

Teaching Imitation Using Discrete Trials (continued) Once the first response is mastered, the same procedure would be used to teach a second response (e.g., waving). After two responses are mastered in individual sessions, they would alternately be presented in the same session (e.g., “Do this” [clapping]; “Do this” [waving]). Over time, additional responses are added until the child immediately imitates any new action the therapist does following the prompt, “Do this.”

Generalization of Skills Skills taught during discrete trials are then generalized to natural settings. e.g., Clapping when another child answers correctly during group instruction or at a recital or school assembly. e.g., Waving to another person when entering or leaving a room.

Billy: Imitating a Model 10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 6 7 8 9 11 12 13 14 15 16 17 SESSIONS PERCENTAGE CORRECT (TOTAL) Baseline Differential Reinforcement + Feedback This is an example of how Billy’s progress is monitored with a particular goal. Prior to implementing an intervention, baseline data were collected on correct responding. During baseline, Billy was presented with 20 2D cards with pictures of items (e.g., car, book, airline, candy ect.) he was able to identify. For example, the therapist held up a picture of a car and said “Is this a truck?” or the therapist held up a picture of a book and said “Is this a book?”. During baseline Billy responded “no” to every instruction that was presented. The therapist did not present any differential consequences during baseline. During baseline Billy was unable to make a discrimination between yes and no. Once treatment (e.g., differential reinforcement + feedback) was initiated correct responses increased to acceptable levels.

Why is ABA Effective with Autism? (continued) Empirical Emphasis: Treatments are based on principles and procedures supported by research. Intensity Level: 25 to 40 hours per week for 3 years.

Early Behavioral Intervention for Autism Lovaas, 1987; McEachin et al., 1993; Smith et al., 2000 Year 1--reduce aberrant behavior, teach attending, imitation, instruction following, speaking in short phrases, play skills, and self-help skills There are a variety of different ABA treatments for autism, but I will illustrate the general approach by describing the program that has received the most attention in the literature and in the press. It involves the application of learning and behavioral principles in a highly intensive and structured approach designed to decrease problem behaviors and increase appropriate behaviors and skills. This approach generally involves 20 to 40 hours per week of one-on-one and small group instruction from highly trained therapists and parents, usually starting during the preschool years and lasting about 3 years. Specific sets of individualized target skills and preferred items or activities (i.e., reinforcers) are developed for each child. The reinforcers are presented to the child following correct responses and appropriate behavior in order to motivate the child to learn new skills and repeat positive behaviors. Aberrant behaviors are prevented or discouraged (i.e., extinguished). Complex skills or tasks are divided into small, simpler steps using techniques such as task analysis and shaping. The child repeatedly practices these tasks either in a series of “discrete trials” or under more naturalistic conditions until the skill is mastered. Because there is a strong emphasis on success, and reinforcement of success, systematic prompts or cues are introduced to increase correct responding and then gradually withdrawn (or faded) to promote independence. Data on target behaviors are collected during each training session and graphed frequently to assess the child’s progress and the effectiveness of the individualized treatment program. These data are reviewed regularly by a senior behavior analyst to help insure that ineffective treatment components are refined or replaced until treatment goals are achieved. Again, although there is variation among programs, the initial goals are often to reduce aberrant behaviors, such as aggression, self-injurious behavior, and stereotypy, and to increase a variety of basic skills, including attending skills, imitation, and following verbal requests from others, speaking in short phrases, appropriate play skills, and self-help skills.

Early Behavioral Intervention for Autism (continued) Year 2--extend expressive vocabulary, more abstract concepts, extend treatment to group and community settings Year 3--pre-academic and academic skills, appropriate emotional expression, observational learning, and interactions and friendships with normally developing peers The major goals of the second year are generally to extend the child’s expressive vocabulary, including more abstract concepts, and to extend the treatment to group activities in classrooms and other community settings. When feasible, the children are enrolled in regular or special preschool programs during the second year with trained therapist serving as one-on-one aids. During the third year, the focus of the program shifted toward pre-academic and academic skills, appropriate emotional expression, observational learning, and interactions and friendships with normally developing peers.

Cost-Benefit Analysis of Early, Intensive ABA for Autism Average lifetime cost for a person with autism is over $4 million Average cost of Early, Intensive ABA is $150,000 over about 3 years Average lifetime savings from ABA Treatment is between $1.6 and $2.7 million

Assessing Children with Autism Periodic assessment for diagnosis and management Ongoing assessment for intervention Before discussing operant mechanisms that may be directly relevant to the diagnosis of autism, I will first briefly describe how functional analysis methods have recently been extended to the examination of complex relations involving multiple operant mechanisms. READ SLIDE.

Periodic Assessment for Diagnosis and Management Identify the child’s overall strengths and limitations Determine the appropriate diagnosis or diagnoses Set the global goals for treatment

Components of a Diagnostic Assessment Genetic/Etiologic workup Assessment of behavior/symptoms Formal audiologic evaluation Cognitive testing Assessment of adaptive behavior Speech/Language evaluation

Ongoing Assessment for Intervention Identify the specific behaviors to be increased Identify the specific behaviors to be decreased Identify effective reinforcers

Assessment of Skills to Increase Attending Skills Compliance Following Simple Instructions Motor Imitation Vocal Imitation Matching Play Skills Social Skills Self-Help Skills

Skill Assessment Areas Imitating Behavioral Chains Following Multi-Step Instructions Categorization Verbal Behavior-Listener Skills Verbal Behavior-Speaker Skills Pre-academic and Academic Skills

Matching Skills Progression Identity matching with objects Identity matching with pictures Matching pictures to objects Matching objects to pictures Matching shapes, colors, letters, numbers Matching on 2 dimensions (color-shape) Matching by categories (e.g., animals, vehicles) Matching objects with their spoken names Matching pictures with their spoken names

Social Skills Progression Shaking hands Making eye contact during greetings Imitating a smile Smiling reciprocally Appropriately getting someone’s attention Appropriately exchanging toys with a peer Playing a simple interactive game (roll ball) Showing appropriate affection (e.g., hugs) Taking turns during a simple game Making polite statements (e.g., “Bless you. “Your welcome.”) Initiating a conversation (e.g., “Did you watch the Huskers game?”)

Preference Assessments Children with developmental disabilities sometimes are not able to tell you what things they like or tell you when they want one thing instead of another. Researchers have developed preference assessments to identify what things people with disabilities like.

Steps of Preference Assessments Step 1: Interview the parent with the RAISD to list the kinds of things that the child likes Step 2: Get the actual items the parent nominated as highly preferred Step 3: Allow the child to select items from the group Step 4: Rank the items from high to low based on what the child chose

Types of Preference Assessments Single-item type – Present each item from the group one at a time Choice type – Present all items 2 at a time and let the child choose between the 2. Group type – Present all items together and let the child select items from the group

Single-item Preference Assessments Developed by Pace et al. (1985) 16 stimuli Each stimulus presented individually 10 times for 5 seconds each The SI method identified highly preferred stimuli for all participants in the study However, subsequent research has shown that the SI method may also yield a high number of false positives *One of the first assessments developed for identifying preferred stimuli was a single-stimulus presentation (SS method) preference assessment developed by Pace et al. (1985). *With this preference assessment, 16 stimuli had been previously identified as potential reinforcers based on caregiver verbal report. *Each stimulus was then presented individually 10 times for 5 s each. If the participant reached for the stimulus, the observer scored an approach response and the participant received access to the stimulus for 5 s. At the end of the 5 s, the chosen stimulus was removed and a new stimulus was presented. Using this approach, Pace et al. found that the SS method identified highly preferred stimuli for all participants in their study. However, subsequent research has shown that the SS method may also yield a high number of false positives (i.e., stimuli that appear highly preferred but do not function as positive reinforcers). The SS method may have a high percentage of approach responses because of the tendency for participants to approach any stimulus placed in front of them regardless of preference.  

Percentage of trials chosen 100 90 80 70 60 Percentage of trials chosen 50 40 30 20 10 Toy Telephone Barney Doll Action Figures Radio Ball Items

Paired-Choice Preference Assessment Developed by Fisher et al. (1992, 1996) Take 5-10 top stimuli from the RAISD Each stimulus paired once with every other stimulus Two stimuli presented concurrently; the participant was prompted to choose one The participants had to emit a choice *To control for false-positive results, Fisher et al. (1992) extended the procedures developed by Pace et al. with a paired-choice preference assessment. During the PC method, the therapist used 16 stimuli, each paired with one another twice. The therapist presented 2 stimuli concurrently then verbally prompted the participant to choose one stimulus. If the participant reached for a stimulus, the observer scored an approach response and the participant received that stimulus for 5 s while the other stimulus was removed. At the end of the 5 s, the chosen stimulus was removed and two new stimuli were presented. If the participant approached both stimuli simultaneously, the therapist blocked the response and represented the two stimuli after a 5-s delay. One benefit of the PC method is that two stimuli are presented concurrently such that participants had to emit a choice response. Choice paradigms have often been used to establish relative preference; thus by having the items available concurrently, Fisher et al. developed a more reliable preference assessment. Despite the utility of the PC method, this procedure has two notable limitations. First, the PC method requires a long time to conduct, which may affect its practicality in some settings. Secondly, the PC method has been noted to occasion destructive behavior in some individuals.

Percentage of trials chosen 10 20 30 40 50 60 70 80 90 100 Toy Telephone Radio Barney Doll Ball Action Figures Percentage of trials chosen Items

Group Preference Assessment- MSWO Multiple Stimulus without replacement (MSWO) developed by DeLeon and Iwata (1996) Compared three different preference assessments (PC method, MSWR, & MSWO) Results obtained from MSWO were comparable to that obtained by the PC method DeLeon and Iwata (1996) evaluated an extension of the procedures described by Windsor et al. (1994). Whereas Windsor et al. replaced stimuli in subsequent trials following the trials in which those items were selected, DeLeon and Iwata did not replace previously chosen stimuli. As a result, participants were required to choose among less preferred alternatives, which resulted in a more discrete ranking of preferred stimuli (based on comparisons between less preferred stimuli). Preferred stimuli were evaluated as reinforcers through a reversal design. Participants were first given 30-s access to each item and then asked to choose one item from the entire array of items. Once an item was chosen it was not replaced in the array and the participants had to chose until all items were selected or until 30 s went by without a selection occurring. All participants showed increases in responding when preferred stimuli were presented contingently. Also compared to Fisher et al and Windsor at al. Results: Windsor et al was the quickest followed by Deleon then Fisher

Percentage of trials chosen 100 90 80 70 60 Percentage of trials chosen 50 40 30 20 10 Toy Telephone Barney Doll Action Figures Radio Ball Items

Preference Assessment Outcome Items that the child chooses are usually the most effective positive reinforcer.

Ongoing Preference Assessments Paired-choice assessment conducted once every 4-6 months Mini-MSWO assessments conducted daily or more frequently

Compliance and Cooperation Training Individuals on the autism spectrum often display problem behaviors in a variety of contexts including: when instructional requests are presented when asked to surrender an unusual object (e.g., piece of dirt) they are holding during instructions

Compliance and Cooperation Training (continued) Teaching a child to accept removal of a preferred object using delay fading. Teaching compliance using least-to-most prompts.

Teaching Tolerance for Instructional Task The traditional approach to treating these problems involves extinction Extinction often produces deprivation from reinforcement, which in turn, may evoke bursts of problem behavior

Teaching Tolerance for Instructional Task (continued) Bouxsein and Fisher (in press) evaluated an alternative to extinction. The alternative involved the provision of a choice between surrendering the preferred object or completing the instructional tasks while retaining the object.

Percentage of Trials with Compliance Choice 100 3-Step Prompting w/ Extinction 3-Step Prompting w/ Extinction Baseline Choice 80 60 Percentage of Trials with Compliance 40 20 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 Session

Percentage of Intervals of Aggression and Disruption 100 Baseline 3-Step Choice 3-Step Choice 80 60 Percentage of Intervals of Aggression and Disruption 40 20 1 3 5 6 8 10 11 13 15 17 19 21 22 24 26 28 31 33 Session

Percentage of Intervals of Choice Allocation Baseline 3-Step Choice 3-Step Choice 100 Task Choice 80 60 Percentage of Intervals of Choice Allocation Item Choice 40 20 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 Session

Compliance Training This case illustrates a simple and effective way to increase compliance while decreasing problem behavior associated with presentation of instructions This may be a result of decreasing the aversiveness of the instruction by allowing the child to choose whether to surrender a object or complete an alternative demand

Improving Vocabulary Skills in Children with Autism Recent behavior analytic work in autism has focused on teaching critical skills, ones that facilitate the acquisition of many subsequent skills (e.g., pivotal responses, behavioral cusps).

Vocabulary as a Critical Skill Children in advantaged homes are exposed to, and learn two to three times as many words as those in disadvantaged homes (Hart and Risley, 1995). Correlation of .78 between parents use of “non-business” words with their kids and later IQ This discrepancy between advantaged and disadvantaged children is not ameliorated through schooling.

Disadvantaged Children 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Age Vocabulary Size Advantaged Children Disadvantaged Children

Vocabulary as a Critical Skill (continued) Vocabulary in the early school years is the single, best predictor of SAT scores and adult literacy. This is why Andy Biemiller has called vocabulary the Missing Link between reading mechanics and reading comprehension or literacy.

Vocabulary and Reading Read the following word and raise your hand when you know what it is: supercalifragilisticexpialidocious

Individualized Vocabulary Lists with Normative Relevance Normative word lists provide information on words that most children know Individualized word lists contain words that a child contacts on a routine basis Identifying words common to both types of lists may produce the larger increases in the child’s working vocabulary

Developing an Individualized Vocabulary List Begin with a word list with a developmental progression Living Word Vocabulary; (Dale & O'Rourke, 1981) http://www.sci.sdsu.edu/lexical/select.php; (Dale & Fenson, 1996)

Developing an Individualized Vocabulary List (continued) Identify words that the child is likely to contact on a daily basis Morning Routine Places, people, activities, items Mealtime Foods, utensils, kitchen and dining room items Playtime Toys, activities, people

Developing an Individualized Vocabulary List (continued) Daycare or school People, actions, objects Places like church, stores, restaurants What is done there, What they sell, What you buy Household chores and activities What they are called, Who does them

Developing an Individualized Vocabulary List (continued) Special events Birthdays, holidays, vacations Sports and hobbies Materials used, players, positions, What they do Things in the yard and neighborhood Animals, trees, vehicles, names of neighbors

Developing an Individualized Vocabulary List (continued) Keep a 3-day diary and write down the names of people, objects, activities, and actions and add any new words to your list

Developing an Individualized Vocabulary List (continued) Enter the individualized list into a spreadsheet next to the normative word list Sort both lists alphabetically Identify words common to both lists Re-sort the lists developmentally Begin teaching common words ordered developmentally

Jack's List Normative Words Dev Lev in Months a 26.5 a lot 29.5 about after 29 ache all 18 air all gone 17 airplane alligator 25 am 28 an   alone and 26 animal 24 ankle 30 ant another apple are any arm 14

Jack's List Normative Words Dev Lev in Months belt ball 9 block bath   book 10 bat baby 11 bib balloon 12 bicycle banana bathtub bye baa baa 12.5 brush bed 13 button belly button breakfast arm apple 14 boat bathroom

Behavior Analytic Approaches to Vocabulary Development From a behavior analytic perspective, teaching vocabulary involves the establishment of specific types of conditional discriminations, ones involving a spoken or written word as component of the four-term contingency.

Conditional Discriminations Involving Deictic Words Children with autism have particular difficulty learning deictic words because they require conditional discriminations (or have shifting referents). Examples: I, you, me; first, last; this, that; here, there.

Conditional Discriminations Involving Social Skills Social approaches to other individuals are likely to produce reinforcement under certain conditions and not others (e.g., requests to play when a parent is busy or not). Interactive play and joint attention require the child to simultaneously attend to objects and people.

Three- and Four-Term Contingencies Stimulus – Response – Reinforcer Conditional Stimulus – Stimulus – Response – Reinforcer With spoken-word-to-picture discriminations, a spoken word is the conditional stimulus that specifies which of the comparison stimuli the individual should respond to produce reinforcement.

Spoken-Word-to-Picture Discriminations “Point to Dog”

Building Working Vocabularies Spoken-word-to-picture discriminations are critical to the development of vocabulary skills.

Functional Approaches to Teaching Conditional Discriminations in Autism Unmotivated learners Learners requiring extra-stimulus prompts Inattentive learners Severely limited learners

10 20 30 40 50 60 70 80 90 100 2 4 6 8 12 14 16 18 Sessions Percent Correct Baseline CB Sr+ Sr+ + Prompt Prompted correct responses s Before discussing operant mechanisms that may be directly relevant to the diagnosis of autism, I will first briefly describe how functional analysis methods have recently been extended to the examination of complex relations involving multiple operant mechanisms. READ SLIDE.

Percentage of Attending Baseline Sr+ Sr+ + Prompt 10 20 30 40 50 60 70 80 90 100 2 4 6 8 12 14 16 18 Sessions Percentage of Attending Baseline CB Sr+ Sr+ + Prompt Before discussing operant mechanisms that may be directly relevant to the diagnosis of autism, I will first briefly describe how functional analysis methods have recently been extended to the examination of complex relations involving multiple operant mechanisms. READ SLIDE.

Teaching Conditional Discriminations to Inattentive Learners Extend prior work on differential observing responses (DORs) by embedding an identity-matching task into a graduated-prompting procedure to teach spoken-word-to-picture relations to children with autism.

Treatment and Control Conditions Verbal prompt to point to test stimulus No feedback for correct or incorrect responses Graduated prompting Sequential verbal, modeled, and physical prompts Praise and edible delivered for correct response following the verbal prompt Identity-matching Identical to graduated-prompting except the modeled prompt was replaced with an identity-matching task ID prompt: Therapist held up a picture identical to the test stimulus and said, “This is Alex. Point to Alex”

Sessions 100 90 Graduated Prompting 80 Identity Matching 70 60 Percent Correct 50 40 30 20 10 Control Jane 5 10 15 20 25 30 35 40 Sessions

Control Graduated Prompting Identity Matching 10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 90 100 Percent Correct Danny 5 15 25 35 Sessions Identity Matching Graduated Prompting Control

Teaching Vocabulary in Autism These cases illustrate how identifying the functional deficit responsible for a child’s poor performance on spoken-word-to-picture relations can be used to develop an effective intervention to improve the child’s working vocabulary.

Vocal Mand Assessment and Training (Bourret et al., 2004) Conducted a preference assessment to identify a high preference item Conducted mand assessment to identify the appropriate training procedure Conducted mand training using the identified procedure

Behavioral Approaches to Verbal Behavior In traditional approaches to speech and language, the focus is on the topography of verbal behavior or what it looks like (e.g., receptive, expressive, phonemes, words, phrases, sentences). Behavioral approaches focus on the functional aspects of verbal behavior (e.g., echoic, mands, tacts, intraverbal, autoclitic).

Behavioral Approaches to Verbal Behavior (continued) Verbal behaviors are learned responses that are defined in terms of the antecedents and consequences of which the behavior is a function: Antecedent Behavior Consequence

Echoic Responses, Mands, Tacts, Intraverbals Antecedent Behavior Consequence “Ball” “Ball” “Good job” Ball on shelf “Ball” Ball given Ball shown “Ball” “That’s right” “What is round “Ball” “That’s right” and bounces?”

Vocal Mand Assessment Each session involved 10 1-minute trials 0 s: No Prompt Hold the high preference item in front of the child 10 s: Nonspecific Prompt: “If you want this, ask me for it.” 20 s: Modeled Prompt: “If you want this, say chip.” 30 s: Phoneme Prompt: “If you want this, say “ch.” Give the high preference item for the remainder of the trial following a correct response.

PROPORTION OF TRIALS Nonspecific Prompt

| FADING | Nonspecific Prompt “Nick” “Ni” PROPORTION OF TRIALS

Social Skills Training Identify one or more peers who are willing to help promote social behavior Identify activities that both your child and the peer enjoy Possible activities include: rolling a ball, Lego blocks, basketball and hoop, puzzles, musical instruments, crayons, play dough, dressing up in costumes, duck-duck-goose, ring-around the rosy, trucks and cars

Social Skills Training (continued) Practice the activity with your child and note any prompts, reinforcers, or assistance you provide. Before the activity starts, teach the peer to deliver the same prompts, reinforcers, and assistance as you did when you practiced with your child.

Social Skills Training (continued) Supervise the initial session closely and deliver praise and preferred items for appropriate social behaviors like, Smiling Initiations, spoken or gestured (“Look”, “Watch me”, “Your turn”, “My turn”) Turn-taking and sharing

Initial Toilet Training Prompt the child to go into the bathroom and pull down their pants. If the child is wet or soiled, clean and change them with minimal attention (don’t talk to the child) and then leave the bathroom. If the child is dry, have them feel their underwear and praise (“Good job! Your pants are dry.”) Have the child sit on the toilet and immediately deliver their most preferred reinforcer and then allow the child to get off the toilet and leave the bathroom.

Initial Toilet Training (continued) Keep a log and record whether the child was wet, soiled, or dry, and whether they voided in the toilet. Repeat 9 more times (or trials), once every ½ hr. For the next 10 trials, set a kitchen timer and have the child sit on the toilet until the timer goes off and then deliver the reinforcer. Mix up the lengths of the toileting sits (e.g., starting with 5, 8, 6, 10, 7, 9, 6, 9, 5, 10, 8, and 7 seconds). If at any point, the child voids in the toilet, immediately praise, deliver the reinforcer and allow them to get off the toilet and leave the bathroom.

Initial Toilet Training (continued) Get the child used to the toilet (cont.). For the next 10 trials, double the lengths of the toileting sits (e.g., 12, 14, 10, 18, 16, 20, 12, 18, 10, 16, 20, and 14 seconds). Continue doubling the lengths of the sits until the child is sitting on the toilet for 5 minutes once every ½ hr. When ½ of the child’s voids are in the toilet, stop providing reinforcement for completing 5-minute toileting sits without voiding (i.e., only voiding in the toilet produces reinforcement).

THANKS Before discussing operant mechanisms that may be directly relevant to the diagnosis of autism, I will first briefly describe how functional analysis methods have recently been extended to the examination of complex relations involving multiple operant mechanisms. READ SLIDE.