A Place To Be And Something To Do: Evidence-based Practices for Children with Autism Samuel L. Odom FPG Child Development Institute

Goals of the Presentation Provide basic information about ASD Examine goals of inclusion Discuss forms of inclusion Describe measure of quality of programs for children with ASD Identify comprehensive treatment models Describe evidence-based focused intervention practices Process of working from goal to practice selection

Introduction 1 in 68

DSM 5 Diagnostic Criteria Impairment in social communication Restricted repetitive and stereotyped patterns of behavior Onset prior to the age of three years

Demographics 75% are male Multiple etiologies related to neurobiological causes Unrelated to socioeconomic status or race Range of IQ scores, but stretches across the continuum

History of Disorder and Trends in Treatment Kanner’s Discovery in 1940s Psychodynamic approaches (Kanner- Bettleheim-Greenspan) Lovaas application of Applied Behavior Analysis Structured psycho- educational approach (Project TEACCH) LEAP and Walden programs among first inclusive programs

Autism Mystique Probably more than any disability, or unique set of abilities, autism has been shrouded in a treatment mystique The etiology has gone from refrigerator mothers to epigenetics Treatments are more diverse than any known disabilities Treatment claims range from amelioration to recovery

Defense Against the Dark Arts Many interventions with no scientific evidence have been recommended for children with ASD

Cutting Edge Interventions for Autism (Seri & Lyons, 2011) Antifungal treatment Aquatic therapy Berad Auditory Integration Therapy Chelation Removal of Toxic Metals Craniosacral and chiropractic therapy Dietary interventions Hyperbaric oxygen therapy Medicinal marajuana Neuroimmune dysfunction and antiviral therapy Sensory gym Traditional and indigenous healing Stem cell therapy Transcranial Direct Current Stimulation

Evidence-Based Practices Translation of the intervention research literature Most based on applied behavior analysis Some from other theoretical perspectives

What Do We Mean By Practice? Comprehensive Models vs. Focused Interventions Focused interventions are procedures that promote individual skills or learning within a specific skill area. Comprehensive models are multi-component programs designed to positively and systematically affect the lives of children with ASD and their families

Definition of Inclusion Placement of children with disabilities in programs with typically developing children Inclusion defined in different ways (Odom, 2002) Forms of inclusion – Community-based – Team teaching – School-based Blended model

Choice of Outcomes (Goals) Determine Supports Needed Social Integration – Activities promoting social interaction with members of the class and community IEP Objectives and Learning Outcomes – Procedures supporting learning goals

Equity as a Fundamental Benchmark Britto, Yoshikawa, & Bollers (2011) social policy report for Society for Research on Child Development Equity is the key concept in establishing early child development programs in internation context – Access – Quality

Outcomes of Inclusive Settings (Schwartz, Staub, Gallucci, & Peck, 1995) Participation – As other classmates Engagement – Meaningful involvement Relationships – Formation of friendships

Comprehensive Treatment Strategies Multiple components Broad scope Intensity Longevity Manualized procedures

Examples of Comprehensive Treatment Program Lovaas Institute Pivotal Response Treatment Early Start Denver Model LEAP** TEACCH Project DATA** Princeton Child Development Institute** Walden** May Institute

Features of CTMs that Focus on Inclusion Assessment and goal development Majority of children are typically developing Class-wide and individual program designed for children Naturalistic and direct instruction Structure and predictability Intensity Parent program Trained Staff

A Technical Eclectic Approach Local programs can and do create their own service models Important to have a conceptual framework or theory of change Necessary to have a proscribed (manualized) system of assessment, treatment selection, and evaluation Necessary to stay close to the science in selecting interventions

Family & Student Priorities Student Characteristics Current Environment Future Environment Professional Development Technical Assistance & Support Program Quality Goals Social Communication Behavior Selection of EBP Selection of EBP Implementa- tion Outcomes Influences Process Model Features

Quality is Important

Learning Environment Interdisciplinary Teaming Program Ecology Structure & Schedule Positive Learning Climate Curriculum & Instruction Communication Social Competence Personal Independence Functional Behavior Assessment & IEP Family Participation Program Quality Learner Outcomes Transition (MHS only)

Autism Program Environment Rating Scale (APERS) Formats Preschool-Elementary – Inclusion preschools – Self-contained preschools – K-5 (or beginning of middle school) inclusive – K-5 self contained Middle School-High School – Inclusive classes (assumes multiple classes) – Self-contained classes – Transition programs

APERS Preschool-Elementary Classroom Environments Class Structure/Schedule Positive Classroom Climate Assessment Curriculum and Instruction

APERS Preschool-Elementary Communication Staff/Peer Relationships Functional behavior (Challenging and Adaptive) Family Involvement Teaming

Evidence-Based Practices

Basing Early Intervention on Evidence-based Practices Should draw from the current scientific information available that documents what works. – DEC Recommended Practices – National Standards Project – National Professional Development Center on ASD

Systematic Reviews of the Literature for Evidence Based Practices (EBPs) In 2009, 11 “treatments” or practices with an evidence base – Reviewed by National Standard Project from National Autism Center In 2010, 24 EBPs – National Professional Development Center (NPDC) – Included 10 years, In 2014, 27 EBPs – Second review by NPDC – Included 22 years, ,101 possible studies  456 studies RCT, quasi-experimental, single case design – Strength of evidence for assessment – Based on number, type of studies using each EBP autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/2014-EBP-Report.pdf Odom, Collet-Klingenberg, Rogers, & Hatton., 2010.; Wong, Odom et al., 2014 RCT: randomized clinical trial

Evidence – Based Practices (2014) Antecedent-based interventions Cognitive behavioral intervention* Differential reinforcement Discrete trial training Exercise* Extinction Functional behavior assessment Functional communication training Modeling* Naturalistic interventions Parent-implemented intervention Peer-mediated instruction/intervention Picture Exchange Communication System  Pivotal response training Prompting Reinforcement Response interruption/redirection Scripting* Self-management Social narratives Social skills training Structured play groups* Task analysis Technology-aided intervention/instruction* Time delay Video modeling Visual supports * Added from 2014 literature review

Evidence-based Practice Approach Wong, Odom et al. (2014)

Selecting an Evidence-Based Practice Goal: skill being promoted Your professional wisdom The learner’s learning style The learner’s temperament The learner’s interests and motivators Supports already in place* History of what has and hasn’t worked

Evidence-Based Practices are Delicious

Facilitators of Early Childhood Inclusion Programs, not children, have to be ready for inclusion – Accepting philosophy – Quality of program (ECERS, ICP, CLASS, APERS) Collaboration is the cornerstone Specialized instruction is essential Adequate support is necessary – Advocate in the administration – Resources for training and collaboration

Delivery of Services autismpdc.fpg.unc.edu/files/NP DC_CoachingManual.pdf Initial training Itinerant coach/ consultant in community child care or school setting

Elements of Successful Coaching Relationships Includes: Trust and mutual respect Training Willingness to change Professional attitude Reciprocity Communication

Trust and Mutual Respect Understand topic-comfort levels Respect coaching partner’s professional skills Use shared terminology Express feelings honestly with compassion Be open to each other’s belief system

Issue of Program Intensity National academy report recommended 25 hours per week of service What do you think about this issue? Intensity defined as engagement and opportunity to learn Intensity directed toward learning goals: what if social integration is a goal?

Questions and Comments?