Autism Spectrum Disorders: Strategies and Interventions Adrianne Da Silva, M.A. Erin Milhem

Cognitive Deficits Executive Functioning Storage and Retrieval of Information of salient information Processing Speed Discrepancies between verbal and nonverbal reasoning skills Abstract thinking and inferencing

Executive Functioning What is it? An umbrella term that includes a collection of related functions that are responsible for goal- directed and problem solving behavior.

Executive Functioning The invisible disability Cognitive delays, autism… All have clear manifestations Executive functioning issues are usually noticed by what the child is not doing. Misinterpreting behaviors often see the kid as annoying, lazy, unmotivated, resistant.

Inability to stop behaviors or impulses Inhibit Inability to stop behaviors or impulses Blurting out answers before being called on Difficulty taking turns Careless mistakes in schoolwork Distraction from task at hand Beginning task without listening to full instructions Answering questions without thinking the question through Difficulty following rules Lack of personal safety and space

Shift/Cognitive Flexibility Difficulty changing from one activity to another Make transitions Problem solve flexibly Switch attention Change focus from one topic to another Cognitive flexibility, or the ability to shift mindsets is requires individuals to interpret information in more than one way, change their approach when needed and choose a new strategy when the first one is not working.

Initiate Difficulties with starting a task, activity, and independently generating ideas, response, or problem solving strategies. Want to succeed at tasks but trouble getting started Need lots of prompts to begin Overwhelmed by large assignments

Working Memory Problems with holding information in the mind for purpose of completing tasks. Trouble remembering things Losing track of what they are doing Difficulty following directions Working memory enables individuals to hold auditory, written, or visual information in the mind long enough to understand a sequence of words and ideas, and allows us to retain facts so that they can be formulated into expressive language in the form of verbal statements, written sentences, or coherent paragraphs. Working Memory Is an active and limited capacity memory system that acquire information from short or long term memory, sensory input, and/or automatic memory, and then holds the information for a short while a task is being performed. It is an important part of the system that has a large impact on academic performance. Working memory is proposed to be the central cognitive control process that focuses the mind, directs mental efforts, accomplishes tasks, and ignores distractions.

Difficulty with managing current and future tasks. Plan/Organize Difficulty with managing current and future tasks. Anticipate future events Set goals, and develop steps to carry out. Sequencing a series of steps Finishing Tasks Getting lost in the details Difficulty sorting and classifying information from the concrete to the conceptual level.

Organization of Materials Problems organizing personal space. Messy desks, backpacks, bedrooms, lockers, etc. Trouble cleaning up after self Keeping track of possessions

Problems with personal monitoring. Rushing through work Careless mistakes Failing to check work Failure to notice if things bother other people Tracking and modifying behaviors and mood states

Emotion Regulation Ability to identify, monitor, and inhibit emotional responses and implement appropriate coping strategies Emotional outbursts Yelling, screaming, swearing Tantrums, Meltdowns, and Rages Physical Aggression and property destruction Low Frustration Tolerance Depression and withdrawal Inability to implement appropriate coping strategies

Common Triggers Losing a game Changes in routine When other students don’t follow the rules When he or she doesn’t get his/her own way When the student gets excited and can’t wind down Misunderstanding directions Thinking that their work is not as good as another student

Deficits that can contribute to Difficulty with Emotion Regulation Difficulty communicating Social difficulties Motor challenges Cognitive challenges Neuropsychological factors (hyperactivity, hypo- activity)

Why is emotion regulation important ? Extreme positive and negative emotions can effect: Communication Attention Problem Solving

Skills Required for Successful ER Awareness of emotions Read and interpret nonverbal expressions of emotions Ability to understand and monitor emotional triggers Clearly and appropriately express the emotion Regulate the intensity and timing of the expressed emotion

Steps for Independent emotion regulation Recognizing the “rumbling” – early warnings signs that the student is starting to escalate Making plans for coping with emotional events or triggers Implementing the plan in an appropriate manner

Recognizing the “Rumbling” As the teacher begin to recognize the signs that the student is beginning to escalate Increased pacing Increased talking or noise making Silly or goofy behaviors restlessness At first, we may have to recognize for them and help them choose a calming strategy Begin teaching the students how to notice their signs

Teaching the Skill Make it as concrete as possible Write it down – make it visual Often children need to be taught that there are degrees of emotions Can be represented with a thermometer or a scale Coordinate with home plans!

The Incredible 5 Point Scale Helps individuals rate the emotional state 1 – I am happy and calm 2 – I am a little upset 3 – I am definitely upset 4 – I’m feel like I getting to the point when I can not control my behavior 5 – I’m unable to control my behavior

Types of Emotion Regulation Strategies Behavioral Strategies motor actions sensory motor strategies Language Strategies Self talk Picture communication devices Advanced Strategies Problem solving Self reflection Perspective taking

The Emotional Toolbox (Attwood, 2004) Helps students identify tools to use that can help “fix” certain feelings Physical Tools Relaxation Tools Thinking Tools Social Tools

Physical Tools Going for a walk or run Playing wall ball Ride a bike Play an instrument Play a sport Stretching

Relaxation Tools Drawing Reading Listening to music Finding a quiet safe place Organizing Using fidget items

Thinking Tools Using self-talk (“things will be ok” “it will go better next time” ) Create a personal antidote that can encourage positive thoughts – write it down – (I can ask for help) Help put the event in perspective for the student Have the student engage in academic work that he or she excels in

Teach and Practice Skills Start out with NEUTRAL situations Role play Social stories Video modeling Develop situations to practice skills – warn the student ahead of time

Reinforce the Use of Appropriate Strategies Reinforce in both practice and real life situations When approaching a high probability situation, rehearse with the student and remind about reinforcer Reinforce immediately Use behavior specific praise, emphasizing language you are teaching the student

Interventions

Response Inhibition Environmental modifications Increase external controls, restrict access to settings or situations in which the child can get in trouble or distracted. Provide external structure by teaching rules that can be applied and generalized to a variety of situations. Increase supervision/physical proximity and offer support to bolster the “stop” function. Implement ways to cue when to control impulses. 1. Minimize the amount of external factors in the environment. 2. Provide external structures by teaching rules that can be applied to a variety of situations., clearly lay out expectations for specific situations so the child knows what is expected. 3. Work out some private cues with the child so that you can help them know when to stop. i.e. put a finger to lips, use a visual image to indicate no interruptions, you can raise hand to remind the child to raise their hands. a. physical proximity to cue the child that it is not appropriate time to talk. You may walk over to stand near child. Goal be subtle and not embarrass them. 4. Can work out an agreed upon non-verbal cue to halt behaviors Dawson & Guare, 2010

Response Inhibition Teaching the Skill Work with the child on identifying the skill being addressed and your understanding of the intent of the behavior. Walk the child through the process, having them practice the skills using a contrived situation, teaching example, or visual aides. Teach alternative to negative behaviors. Reinforce the child immediately for using the skill Teach them repair strategies 1. “I think you talk out because you’re looking for recognition from me or your classmates. We’re going to work on raising your hand before you speak” In selecting the replacement skill (e.g. hand raising) make sure the skill being taught meets the same need (i.e., peer or teacher recognition). Or beginning assignment before having all the directions… 2. Practice the skill sufficiently so that the child can be successful most of the time. 3. Replace a negative behavior with a different, possibly unexpected behavior. i.e. “Jared here is a pip cleaner for you to hold in your hands while we wait for the show to start. Keep your hands busy with the pipe cleaner instead” Dawson & Guare, 2010

Shifting/Cognitive Flexibility Environmental modifications Create a consistent, predictable environment as much as possible. Create Visual Cues for routines and schedules. Highlight changes to the routine and help the child build a bridge from the familiar to the unfamiliar. Allow additional time to adjust to changes in routine Provide additional support during transitions. Provide external reinforcers Shifting requires a child to interpret information in more than one way, change their approach when needed and choose a new strategy when the first one is not working. Try to create continuity from one day to the next, even in the midst of change, and minimize the number of “expectations” to the general schedule. Post a daily schedule. Provide a calendar to use to keep track of the larger picture, have them fill it out on their own with some help. When the child asks about upcoming events refer them back to the calendar to help with reinforcing the ritual of checking the calendar. Trial and error helps kids learn how much time is needed to prepare for changes. The general guideline of “not too far in advance but not at the last minute” has to be customized for age and temperament of each individual. Be very explicit about highlighting what will be the same and what will be different. “Look at the calendar with me… 4. Provide extra time to process changes depending on processing speed and level of flexibility of the individual you are working with. 5. Assign a peer buddy for transition times. Assign a job to focus the individual during transitions (i.e. carrying something or turning off lights, etc). Stay near a chld during transition times. Provide verbal support and prompting through the process. Provide advance warning to allow the individual to prepare for upcoming transitions.

Shifting/Cognitive Flexibility Teaching the Skills Teach the child to walk through new situations. This includes self-talk (e.g. “this is different but doesn’t mean it is bad). How/when to ask for help. Teach to use a calendar/schedule Model multiple ways of approaching a task or situation Teaching ways to self reinforce Teach how to use the calendar. When they ask about upcoming events, refer to the calendar. Have them work on setting up daily rituals such as crossing off each day or events as they happen to help with keeping track. Have them reference the calendar or schedule throughout the day. Preparing for many tasks requires flexible thinking on many different levels. Children need to be able to extract information from a variety of sources. Memorizing specific details and integrating them with the larger concepts also require cognitive flexibility. Individuals with ef difficulties often experience an overload of information, so that they do not know where to begin and because they do not shift flexibly they cannot sift and sort the information. Roll switching-This helps them shift perspectives to check whether they have explained information clearly and have supported their arguments with enough details. Meltzer, 2007

Initiation Provide external structure in the form of general guidelines, cues, and support Develop schedules and routines. Use technology Begin task with the child Reward completion of tasks Small groups or peer work Self-understanding/Reflection Many people who have difficulty initiating tasks also have problems with planning and organizing/cognitive flexibility. Their difficulty with getting started may be exacerbated by the fact that they are overwhelmed by the task and don’t know where to start. They may need more guidelines and support to break down the tasks into components and parts. (will address more in the planning and organizing slides). Once an activity becomes automatic, the need for the initiation function is significantly reduced. Alarms, timers and other external aids can help cue the start function. Some children spend an inordinate amount of time starting a task, just thinking, particularly when faced with a school work or writing tasks. try talking through the task with them. Talk about what they need to do and how to break down the steps. to get them rolling, you might even try giving them the first sample step or writing it down. 5. May benefit from setting up their own rewards for completing task. 6. Small groups allow people to gain momentum from the energy and focus others bring to the project. Working together can help break down tasks as each member is assigned to certain pieces. This can help from compensates for executive skills and weaknesses. 7. Reflection and self understanding are key for individuals to be able to assess where strengths and weakness lie and areas that they can focus on strengthening. Reflection rubrics can be helpful tools to provide children with guidance on improving. Understanding these areas can help motivate individuals and anticipate areas where they need more support, and planning. Studies have shown that collecting their own self-monitoring data, that desired behaviors increases. Meltzer, 2010

Environmental Modifications Working Memory Environmental Modifications Visual schedules and check in with schedule throughout the day Verbal cues or prompting Timers Work boxes Develop structured systems for organization (i.e. worksheets, checklists, etc.) Written and verbal reminders Visual cues all prompt heightened attention and contribute to our ability to remember. Repair strategies…. Meltzer, 2010

Working Memory Teaching the Skills How to attend to details Repetition, rehearsal, and review Attaching meaning Editing/Chunking information Many researchers believe that without attention there is no memory. Focusing attention is imperative for efficient working memory. The brain’s ability to make connections, retain information, and retrieve it is enhanced by heightened attention. If information is not marked as important or relevant by the brain, most of it will enter short-term memory very briefly and then will be gone before it is stored in long-term memory. Heightened attention makes information, experiences, or processes stand out in the brain, and is the vital first step in separating relevant information from other sensory input. The brain benefits from a signal, either external or internal to prompt it to focus when something important is coming. Sustaining attention may be difficult for kids. External factors such as other kids, activities or noises may distract them, internal distractions may be equally disruptive to a child’s sustained attention. Individuals who are preoccupied with the anticipation of an upcoming event, the processing of a past event, or the workings of their imagination cannot easily attend, and therefore cannot easily remember information. All children benefit from developing greater awareness of the role that attention plays in memory and from learning executive function strategies to improve their ability to direct and sustain their attention 2. To cement a small amount of the information in memory, it may be helpful to “visit” it again, that is to repeat reherse, and review information. Verbal rehearsal of needed information can provide an auditory stimulus when children hear themselves repeat the information. Copying materials over may also be helpful, as the combined effects of the visual focus of reading and the motor rehearsal of writing engage both the visual and kinesthetic modalities and make the rehearsal more effective. Rehearsal may emphasize primarily visual pathways. Repetition may also involve the kinesthetic rehearsal. i.e. students can tap on numerals to reinforce their learning of addition facts. Students will benefit from awareness of the rehearsal modality or modalities that are most effective for them…visual, auditory, kinesthetic, and/or tactile. 3. Attaching meaning to new information is a powerful memory tool. A framework or background knowledge provides individuals with cognitive associations that make it easier for the child to incorporate, comprehend, and retrieve the new information. Understanding new information is often facilitated by a comparison to something familiar and known. Information that individuals need to learn can be given additional meaning by intentionally creating associations with a child’s preexisiting background knowledge or by using verbal and visual associations, acronyms, rhymes to make it meaningful. Timelines, information maps, webs, and charts also help to organize information and create associations. Chunking information or combining ideas into fewer units helps people to store and retrieve information. These groupings can be verbal or visual and may be based on sequential blocks of information or a variety of categorical groups. Examples of chunking of information is phone numbers, social security numbers are easier to recall because they are grouped into a three-digit area code, three digit prefix, and four digit number locator. Chunking information makes it more effective to remember more bits of information. Meltzer, 2010 Dawson & Guare, 2010

Environmental Modifications. Plan/Organizing Environmental Modifications. Provide a plan or schedule Break projects into clearly defined subtasks and attach deadlines to each subtask Avoid asking opening ended questions or random questions in class or group setting Create a templates Offer examples of previously finished projects Rubrics/schedules help individuals to envision the endpoint and make task requirements explicit for all students. Providing both rubrics and samples also addresses the needs of students with multiple learning styles, including learners who prefer visual, verbal, part-to-whole, and gestalt-based approaches. You don’t want to ask kids in the middle of class or group situations random questions because they can struggle with retrieving information. Not asking open ended questions in class or in front of others. In private you can ask them open ended and be prepared to assist them through that. Dawson & Guare, 2010

Planning/Organizing Developing an accurate understand of time Teaching the Skill Developing an accurate understand of time Strategy notebooks Ability to assess and breakdown tasks Prioritizing Tasks Obligation Aspiration Negotiation Monitoring Progress Unlike the five basic senses which are innate awareness of time relies on memory to provide cues for future predictions. i.e trying to guess how long it has been since one has last had something to eat, one might consider all the events that have taken place between the last meal and the present time. It is important for individuals with planning and organizing deficits to learn to identify the factors leading to over- or underestimations of time, and that they are offered regular opportunities to hone their estimation skills. Overall, an accurate understanding of time provides a strong foundation from which individuals can begin to predict how different activities will fit into their schedules. 2. Develop a personalized notebook in which they jot down the strategies that work best for them. These notebooks provide individuals with a place where they can easily store and refer to their favorite strategies so that practice and organizing is made easier. 2. Once children possess understanding of time for task they can estimate the length of time they should give tasks. First necessary to divide projects into small manageable parts. Next to accurately predict the length of time it will take to complete each part. Precision for predicting the duration of an activity depends on that child’s memories of previous experience. Prioritizing requires an understanding of each task and the role it plays in larger assignments. It provides a foundation on which kids can build their schedules. Once tasks have been grouped according to their importance, students can rely on their knowledge of time and task to allot the appropriate amount of time for each activity. Obligation are activities that are mandatory tasks that are time sensitive such as homework, jobs, and chores. Aspiration are activities that do not have immediate time constraints and are flexible. These are not critical as either obligatory or aspiraitonal tasks. Negotiation activities do not have immediate time constraints and are flexible. Monitoring Progress learn to rearrange schedules, identify inefficient behaviors, and delegating or deleting responsibilities based on progress. Reflecting on current time management strategies and recognizing when they have overextended themselves, but also to identify circumstances in which they have not performed at their optimum level because of inefficient time management strategies. Meltzer, 2010

Organization of materials Help develop a system for organizing a backpack System for organizing schoolwork and homework Coming up with a system for organizing room Work to help child understand the negative and positive consequence of material management Can use colored folders or even visual aid systems to helps support increased organization. Some people benefit from visual aides for getting out the door in the morning to help remember and keep track of all important things that need to go with them.

Physical Structure Clear physical and visual boundaries. Boundaries help to understand where each area begins and ends. Boundaries help establish context and segments the environment. Minimize visual and auditory distractions. Establish behavioral expectations

Routines Use the need for routine in a positive way by teaching and building productive and functional routines that individual’s with ASD will use now and in the future Characteristics: generalizes, go throughout the lifespan, promotes independence.

Routines First work, then play. Concept of finished. Top to bottom. Left to right. Check schedule. Follow directions / instructions.

Schedules / Transition Systems Visually communicates what activities will occur and in what sequence. The concrete reference to the schedule helps promote flexibility. Individualized at the individuals most independent level of understanding. Needs to be used by the individual.

Schedule / Transition Systems Assess visual level of understanding (functional vs. representational objects, pictures, photos, words, etc..). Assess an amount of visual information to be used in schedule (one at a time, part day, full day, etc..). Select a process for using the schedule (how to sequence and concept of finished).

Work Systems Gives the individual 4 pieces of information in a visual format: What work/activity? How much work/activity? When finished? What’s next? – reinforcement Cause / effect

Work Systems Identify: Types of routines - left to right, top to bottom. Symbols to be used - letters, numbers, color, written, etc.. Concept of finished – box, shelf, drawer, file folder, etc… Reward or motivator.

Visual Structure Visually communicates information on how to complete the activity or direction. Helps to combine and organize a series of elements to obtain a desired outcome.

Visual Structure Teaches flexibility. Promotes generalization of skills. Promotes meaningfulness within activities. Examples: objects; pictures; written instructions; jigs; product samples, etc.. Visually communicates information on how to complete the activity or direction. Helps to combine and organize a series of elements to obtain a desired outcome.

Visual Structure

The 5 Point Scale

How Does Your Engine Run System for monitoring arousal levels in young children High Just right Low