Improving ASD Treatment Outcomes Integrating Speech-Language Therapy and Applied Behavior Analysis Emily Graham, M.A., CCC-SLP & Jason Majchrzak, M.S., L.L.P., B.C.B.A.

What is Applied Behavior Analysis? Applied: Address socially important behaviors Behavioral: Focus on behaviors we can see and measure Analytic: Use data to show treatment had an effect Technological: Therapy can be explained and taught Conceptual: Based on what we know about human behavior Effective: Therapy gets strong, socially important results Generalizable: Newly trained behaviors can occur across a variety of times and settings.

Goals of Applied Behavior Analysis Teaching new behaviors/skills Talking, dressing, toileting, using utensils, Pre-academic and academic Increasing current behaviors/skills Improve demonstration of a skill Reducing barriers Slow progress in school, language, social skills Reducing problem behaviors Tantrums, aggression, self-injurious behavior

ABA Therapy Assessment by BCBA Treatment plan created based on child’s individual needs Goals established in partnership with parents Evidence based strategies to achieve goals 1:1 center-based therapy sessions with ABA Implementer

ABA and Communication – Use Language Functionally Requests Naming Responding to questions Following instructions Asking for information Reciprocal conversation Social skills Feelings identification and expression Reducing problem behaviors

ABA: Parent Involvement Collaboration with therapy services Parents are experts on their kids! Participate in treatment development Learn therapy strategies and do therapy at home! Stay in touch and talk with your BCBA often! Collect data at home.

What is Speech-Language Therapy? Start with assessment by an SLP, who will give recommendations for treatment Many methods of intervention to achieve goals Improve communication skills, understanding skills, social language skills, non-verbal communication, play skills, articulation/phonological development and suprasegmental features of speech Focus on building skills for functional communication and social interaction

Speech-Language Therapy Although children on the autism spectrum may share a similar diagnosis, intervention methods and goals may vary widely based on the communicative level of the child Low-functional verbal: may repeats words (echolalia) and recites scripts but and has delayed functional language Non-verbal: limited to no spontaneous or imitated verbal language Hyperverbal: talks non-stop about topics only he/she is interested in without being able to read the social cues of others or take turns in conversation

Verbal Language/Sign/AAC/PECS Foundation Skills For Functional Higher Level Language Eye Contact Joint Attention Gestures Give/Show Reciprocal Interaction

SLP Modalities of Communication Verbal language PECS (Picture Exchange Communication System) Sign Language/Gesture AAC (Augmentative and Alternative Communication) Total communication approach: using any combination of the above modalities

SLP Methods of Intervention Shaping Imitative Speech: Strengthening the effects of reinforcement with the aim to increase number of vocalizations and verbalizations Gradually increase complexity of the utterance “Buh” to “buh-buh” to “bubble” Modeling Imitative Speech: Provide a prompt for requesting, commenting, responding, describing, negating, etc., as you would want the child to say it Praise the imitative attempt with a desired object or verbal praise and reinforce with repetition Echo Expansion: Appropriate when child is using single words more consistently Add an additional word to a spontaneous production and praise when done correctly “Bubble” to “bubble please” to “more bubble please”

SLP Methods of Intervention Errorless Learning Goal is to replace echolalia with functional speech Prompting, shaping and fading Yes/No: hold up a desired item, ask “do you want ____?” Prompt the child to say “yes,” and give visual cues Prompt is then faded with less volume and emphasis Structured Social Play Turn taking, both verbally and in play Peer play groups with structured activities Play-Based Therapy DIR (Developmental Individual Difference Relationship-Based Model) Greenspan Approach, Floortime and PLAY Project The Hanen Method Visual Language Learning Social stories Visual schedules PECS sentences

ABA + Speech Working Together for Best Outcomes Implementing best communication modality for the patient across both therapies Sharing strategies and techniques and increasing impact at home, school, and in the community Generalization of skills learned in speech therapy to ABA and vice versa Encouraging consistency to prevent conflicting recommendations and methods Using similar terminology or clarify unfamiliar terminology (i.e., manding versus requesting)

Parent Involvement Be an active participant in your child’s therapies! Observe sessions, as appropriate, to carry-over skills into the home environment You may request communication between your child’s therapists (must use release forms) Sharing progress notes and treatment plans Be open about child’s successes and struggles within other services and environments (school, daycare, play groups, etc.)

Case Study #1 Layla is a 3-year-old with ASD and a moderate-severe receptive and expressive language delay. She is verbal, with an approximately 100, single-word vocabulary and occasional 2-3 phrases, some of which are repetitive scripts from TV shows or nursery rhymes. She often perseverates on labeling numbers, colors and letters. She repeats questions that are asked of her. She follows only 1-step directions some of the time. Symbolic play is a relative strength, but she will not take turns in play. She is not yet toilet trained. Poor behaviors are frequent and include hitting, throwing, and severe tantrums when she does not get her way. Parents would often give Layla what she wanted as soon as she started tantruming to avoid a bad behavior. Tantruming behaviors often lead to hugs and coddling to try to get her to calm down.

Interventions Speech Therapy: Initiate PECS to supplement verbal language, errorless learning, echo expansion, structured social play and play-based language learning play. Have the child take the lead in therapy session to find a toy of interest, model appropriate request. One toy at a time to work on requesting, waiting and cessation. Work on following directions with visual cues and slowing fading them. Visual schedules put into place to help her understand what came next in therapy sessions. ABA Therapy: ABA recommended the use of social stories to help Layla understand expectations. ABA worked with the family in order to identify that Layla often acted out to get attention or access to things that she wants. Parent attention could then be focused on ignoring poor choices by Layla and engage her when she was doing well. A behavior plan was also set to remove and restrict access to desired things when Layla didn’t follow directions. A behavior plan also included a strategy, asking Layla a series of 3 questions, unrelated to her scripting, when scripting started, as a way of redirecting continued scripting.

Case Study #2 Jake is a 2-year-old non-verbal male. He is able to combine vowel and consonant sounds spontaneously but does not produce sounds in imitation. Jake sometimes has tantrums (crying, falling to the floor, runs away) when he does not get something he wants or when it is not given quickly enough. He has very poor eye contact. Play skills are very decreased for his age, as he often lines up toys, stacks toys or visually inspects parts of toys rather than playing appropriately with them. He does not take turns in play or give objects on request.

Interventions Speech Therapy: Implement PECS and sign language for building functional language and requiring eye contact be given with each exchange. Shaping imitative speech for turning vowel and consonant sounds into closer approximations of words. Modeling appropriate play with verbal narration. Speech implemented ABA goal for waiting for something after a request, which was part of his behavior plan. ABA Therapy: Implement PECS and sign language during Jake’s ABA therapy session. PECS is used with different people and to request things he wants, ask for help. When the ability to imitate speech sounds was achieved, this skill was practiced in ABA, requiring approximations of things he can say to get a desired reward. Behavior therapy helped at home and in speech therapy to teach Jake to wait to get things he wants and also limit how long he gets with his highest preferred activities, setting up opportunities for him to then request again in the future.

Case Study #3 Simon is a 5-year-old male, who is very verbal, but has some grammatical errors in his speech as well as an articulation delay. He likes to talk about airplanes and Thomas the train. Simon will bring up these topics of interest all of the time and has a hard time talking about anything else in a conversation. He has poor eye contact and limited attention to tasks that do not interest him. Simon has difficulty following others in group and social tasks, often refusing to go along with things his parents and other caretakers suggest or say. Simon has demonstrated the ability to follow directions but often chooses not to, arguing and refusing most instructions. A strength has been Simon’s ability to regulate his own behavior based on instructed rules.

Interventions Speech Therapy: Enroll the patient into a structured social play group to work on reciprocal communication, verbal turn taking in conversation and topic maintenance. Grammatical errors would be targeted through play-based language tasks and story cards in a 1:1 setting. Articulatory errors would be evaluated and approached in drill play. Eye contact would be requested during all verbal and gestural exchanges. ABA Therapy: During social skills group, Simon would learn some basic social rules about participation and cooperating with others. These rules would then be practiced and enforced during social time. Use of language during social skills time would work to enforce grammatical error corrections. Simon would communicate with others, using full sentences during group. Carry-over of articulation goals from SLP would be offered in ABA sessions. Eye contact would also be required when speaking with repeated drilling until eye contact was attained.

References Koenig, M. & Gerenser, J. (2006) SLP-ABA: Collaborating to support individuals with communication impairments. Journal of Speech and Language Pathology-Applied Behavior Analysis. 1, 2-9. Koenig, M. & Gerenser, J. (2011). Powerpoint from ASHA Convention ‘11: SLP-ABA Collaboration on Autism Support Teams. San Diego, CA Parker, Robin. "Incorporating Speech-Language Therapy Into an Applied Behavior Analysis Program." Behavioral Intervention for Young Children with Autism. Austin: Pro-Ed, Inc., 1996. 297-306.

Questions? Thank you!