Overview of the CARD Approach to Applied Behavior Analysis for Children with Autism

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Overview of the CARD Approach to Applied Behavior
Analysis for Children with Autism
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Presentation Outline

• Introduction to CARD
• Brief introduction to ABA and autism
• How to teach Components of a comprehensive ABA
  program for children with autism
• What to teach CARD curriculum

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Introduction to CARD

• Founded in Los Angeles in 1990 by Dr. Doreen
  Granpeesheh
• Mission give top-quality ABA to the maximum
  number of children, around the world
• 15 locations in U.S.A.
• 2 locations outside U.S.A. New Zealand, and
  Australia
• Consultation in Asia, Europe, Middle East, and
  South America

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What is ABA?

• Applied Behavior Analysis
• ABA is the use of scientific principles of
  learning and motivation to teach effectively
• The core concept is that the consequences of what
  we do affect what we learn and what we will do in
  the future
• Positive reinforcement behaviors that produce a
  good outcome are more likely to occur in the
  future
• People are motivated by what they get out of what
  they do
• Examples money, feeling good for helping
  someone, approval from others, satisfaction of a
  good book, etc.

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Positive Reinforcement

• The ABA approach to autism is to identify what
  motivates each individual child
• Every child is different
• Teaching must use what is motivating to the
  child, not what we think should be motivating to
  the child
• Then we teach the child by teaching new skills in
  very small steps and rewarding the child with
  positive reinforcement when they make an effort
  at learning

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Accountability and Effectiveness

• ABA assumes that if a child is not learning, it
  is NOT the childs fault, it is our fault
• We must change the way we are teaching
• We must continue to try different ways of
  teaching until we find one that works
• ABA is the best method for finding what works
• We never blame the child if learning does not
  happen
• We believe its our responsibility to figure out
  how to teach whatever the child needs to learn

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Outcome Research on ABA for Autism

• Lovaas (1987)
• Smith (2000)
• Sallows (2005)
• Howard (2005)
• Cohen (2006)
• Eikeseth (2007)
• Zachor (2007)
• Remington (2007)
• Perry (2008)

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Support for ABA as a Treatment for Autism

• Surgeon General
• NY State Department of Health
• National Academy of Sciences
• American Academy of Pediatrics
• The effectiveness of ABA-based intervention in
  ASDs has been well documented through 5 decades
  of research by using single-subject methodology
  and in controlled studies of comprehensive early
  intensive behavioral intervention programs in
  university and community settings. Children who
  receive early intensive behavioral treatment have
  been shown to make substantial, sustained gains
  in IQ, language, academic performance, and
  adaptive behavior as well as some measures of
  social behavior, and their outcomes have been
  significantly better than those of children in
  control groups.

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Outcome Research on ABA for Autism

• Conclusions of outcome research
• Every published study demonstrated very large
  treatment effects
• Replicated across research groups, across
  university vs. community settings, and across
  continents
• Intensity matters at least 30 hours per week of
  one to one intervention for more than a year
  produces best outcomes
• Duration matters two or more years of
  intervention

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Comprehensive ABA Programs

• Earliest versions of ABA programs focused mostly
  on discrete trial training (DTT)
• Comprehensive ABA programs now include a variety
  of behavioral teaching strategies
• DTT
• Natural Environment Training (NET)
• Verbal Behavior
• Challenging behavior
• Data collection
• Programming for generalization

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Discrete Trial Training (DTT)

• Breaks down learning opportunities into
  well-controlled, discrete teacher-student
  interactions
• Instruction ? Correct Response ? Reward
• OR
• Instruction ? Incorrect Response ? Correction

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Discrete Trial Training (DTT)

• Provides structure for the learning interaction
• Provides a very large number of learning
  opportunities in a small amount of time
• Is proven by hundreds of studies to be an
  effective teaching procedure

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One Discrete Trial
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Many Discrete Trials
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Natural Environment Training

• Naturalistic behavioral teaching procedures go by
  many names
• Incidental Teaching, Pivotal Response Teaching,
• Basic approach
• Teach in the natural environment
• Set up situations where the child will be
  motivated (e.g., toy out of reach)
• Wait for child to initiate
• Prompt the correct behavior
• Reinforce it

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Natural Environment Training

• Much more natural approach than DTT
• Less structured
• Looks more like typical interactions
• Great for teaching play and social skills
• Great for establishing generalization of skills
  learned in DTT
• Some children prefer NET over DTT
• Proven by dozens of studies to be an effective
  teaching procedure

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Verbal Behavior

• B.F. Skinner, Verbal Behavior (1957) Applied
  principles of behavior analysis to language
• Separates language into categories by function
• Reminds us to teach all functions of words
• Teaching one function does not necessarily lead
  to learning other functions of the same word
• Example if we teach a child how to say red, he
  may not actually be able to say red when he
  wants something that is red

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Verbal Behavior

• Most comprehensive ABA programs incorporate
  Skinners analysis of verbal behavior into their
  treatment
• Some incorrectly say that Verbal behavior is not
  ABA or We dont do ABA, we do verbal behavior
• Verbal behavior is one area within ABA, it is not
  seperate

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Challenging Behavior

• Examples aggression, self-injury,
  self-stimulatory behavior, tantrums
• ABA assumes that children are getting something
  they want from challenging behavior
• Attention
• Escape
• Toys or food
• Sensory stimulation
• Autism is NOT the cause of bad behavior

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Challenging Behavior

• First step is to do a functional assessment
• This means assess what they child is getting from
  their challenging behavior
• The next step is to not give it to them any more
  when they have the behavior (extinction)
• AND teach the child a more appropriate behavior
  that will get them what they want
• Example asking for a break, playing with a toy,
  asking for attention, etc.

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Data Collection

• Good ABA programs take lots of data on the
  childs progress
• Frequency of challenging behavior
• Percent correct on skill teaching
• Data are graphed after every teaching session
• The percent correct should be increasing over
  time if the child is learning

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Data Collection Teaching If / Then Reasoning
Baseline
Teaching
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Data Collection Accidents During Toilet Training
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Data Collection Compliance with Instructions
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Generalization

• Comprehensive ABA programs must explicitly focus
  on generalization
• Generalization does NOT occur automatically
• Generalization is NOT an afterthought or
  side-effect
• Generalization is THE central goal of
  intervention

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Planning for Generalization

• Best way
• Teach skills in many different environments
• Teach with many different teachers
• Teach during many different times of day
• Do NOT do the same thing the same why all of the
  time
• When skills are learned in DTT, make sure to
  practice them in natural settings
• Parents must practice all new skills as often as
  possible

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Therapist Training

• ABA therapy is difficult to do
• Its much more structured than feels natural
• It takes a LOT of training to learn how to do it
  correctly
• 20-30 hours of initial classroom training
• Another 30 hours of hands-on training with
  children

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Supervision

• Good ABA programs provide approximately 2 hours
  of supervision for every child, every two weeks
• Supervisors must be experts in ABA, with several
  years of experience
• Every therapist that works with the child is
  directly observed working with the child
• Every therapist is given specific and immediate
  feedback on good and bad performance

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Workshop Model

• There arent enough ABA experts in the world to
  provide supervision
• Another option is the workshop model
• For families who do not live within an hour drive
  of an ABA clinic
• A consultant travels out to familys home and
  trains everyone
• Then the family runs the program and manages the
  therapists
• Consultant follows up with regular contacts

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• Overview of CARD Curriculum

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The CARD Curriculum
Academic Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive Skills
Play
Language
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A Comprehensive Curriculum

• What needs to be taught in ABA programs for kids
  with autism?
• Autism is defined by global deficits
• If we want to catch kids up to typical
  development, we need to teach EVERYTHING that
  they are delayed in!
• That is what the CARD curriculum was designed for

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CARD Curriculum

• Every area of human functioning is addressed in
  the eight content areas
• Each content area in the curriculum is broken
  down into dozens of teaching programs
• Each program is broken down into many (up to 20
  or more) specific instructions along with the
  correct child behavior
• Lessons are arranged in the order in which they
  emerge in typical development

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Language
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Language Curriculum
Language
31 Lessons by Emerging Age and Function

• 0-12 mos.
• Body Parts
• Echoics
• Following Instructions
• Gestures
• Sound Discrimination

• 1 - 2 yrs.
• Actions
• Basic Mands
• Categories
• Choices
• Functions
• Negation
• Objects
• People Relationships
• Prepositions
• Yes / No

• 2 - 3 yrs.
• Adverbs
• Attributes
• Features
• Gender
• Manding for Information
• Opposites
• Pronouns
• Wh-Discrimination
• Locations
• Plurals

• 3 - 4 yrs.
• Describe
• Sequences
• Statement - Statement
• 4 - 5 yrs.
• Same / Different
• 5 - 6 yrs.
• Ask Tell Discrimination
• Statement Question
• Syntax
• 6 - 7 yrs.
• What Goes With

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Language Curriculum
Language

• Each lesson
• Goes beyond teaching the meaning of words
• Because we cannot assume that once the child has
  learned the meaning of a word that she will use
  it in all possible situations
• We need to make sure a child can use a word in
  all of its functions

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Language Curriculum
Language

• Example
• We teach the child to hand us an apple when we
  say Give me apple (receptive)
• We teach the child to respond apple when shown
  apple asked What is it? (expressive)
• This does not mean the child will now be able to
  respond apple in other situations or ask for
  apples when he/she wants them

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Language
Language Curriculum
Instruction or Setting
Consequence (Reinforcer)
Behavior
Function
apple is matched with apple
Matching
Put with same
Praise
Touch apple
Selects apple
Praise
Listening
Vocal Imitation
Someone says apple
apple
Praise
Request
Hungry and no apple present
apple
Child gets an apple
Praise
Labeling
apple
Apple is present
Praise
Conversation
What is your favorite fruit?
apple
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Play
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Play Curriculum
Play
Domains
Sensorimotor Play Task Completion Play Play
Stations
Independent Play
Early Social Games Read-to-Me Books Nursery
Rhymes Music and Movement Treasure Hunt Card and
Board Games Locomotor Play Peer Play
Block Constructions Structure Building Sand and
Water Constructions Clay Constructions Arts and
Crafts
Constructive Play
Interactive Play
Functional Pretend Play Symbolic Play Imaginary
Play Sociodramatic Play
Pretend Play
Audio and Video Play Computer Play Video Games
Electronic Play
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The CARD Curriculum
Adaptive
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Adaptive Curriculum
Adaptive
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The CARD Curriculum
Motor Skills
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Motor
Motor Curriculum
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The CARD Curriculum
Social Skills
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Social Skills Curriculum
Social Skills
Social Language Greetings and Salutations Social
ID Questions Prosody Regulating
Others Conversational Audience Physical Context
of Conversation Listening to Conversation Initiati
ng Conversation Joining Conversation Maintaining
Conversation Repairing Conversation Transitioning
Topics of Conversation Ending Conversation
Non-Vocal Eye Contact Non-Vocal Imitation Body
Language Facial Expressions Gestures to
Regulate Social Interaction
Absurdities Figures of Speech Humor and
Jokes Whats Wrong?
Social Interaction Apologizing Assertiveness Compl
iments Cooperation Negotiation Gaining
Attention Introductions Levels of
Friendship Sharing Turn-Taking Lending
Borrowing
Group Related Skills Responding in Unison Group
Discussion
Self Esteem Dealing with Conflict Positive
Self-Statements Winning Losing Constructive
Criticism
Social Rules Compliance Following
Rules Community Rules Politeness Manners
Social Context Responding to Social Cues Learning
Through Observation
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The CARD Curriculum
Academic Skills
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Academic Skills Curriculum
Academic Skills
Language Arts Colors Community Helpers Handwriting
and Penmanship Writing Letters Spelling Print
Concepts Literary Genres Decoding Word
Recognition Phonics Sight Reading Comprehension
Oral Story Comprehension Reading
Comprehension Phonological Awareness Phoneme
Isolation Phoneme Blending Segmentation Phoneme
Matching Phoneme Manipulation Word Discrimination
Segmentation Rhyming Syllables
Math Shapes Money Patterning Calendar Addition Sub
traction Statistics and Data Analysis Number
Concepts Numbers Counting Quantities Quantitati
ve Concepts Ordering Numbers Groups Comparisons
Number Patterns Time Time of Day Daily
Activities Telling Time
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The CARD Curriculum
Cognition
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Social Cognition

• First, what is social cognition?
• Understanding other people and their mental
  states
• Perspective-taking
• Theory of mind
• Why do we care about social cognition?
• Because good social skills depend on being able
  to understand others
• Children with autism often have difficulty with
  social cognition, even after they have achieved
  age-appropriate verbal behavior

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Social Cognition

• The purpose of the CARD social cognition
  curriculum is to identify which private events
  our clients need to respond to in their peers
• Then identify which public stimuli are hopefully
  correlated with them
• Then teach our clients to respond in a socially
  appropriate and successful manner to those
  stimuli

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CARD Cognition Curriculum Overview
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Social Cognition Overview

• Based on age-levels and progression of skills in
  typical development
• Breaks down each skill area into its own program
• Programs are sequential, starting with earliest
  skills to emerge

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Social Cognition Overview

• Progression from simple to complex
• 1st Person child learns about his/her own
  perspective (self-awareness)
• 3rd Person child learns about other peoples
  perspectives (social cognition)
• Increase subtlety and difficulty
• Apply new learned skills to real environments
• Role-playing with therapists
• Teach rules for effective social interaction
• Test (and teach) in the real environment with
  peers

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The CARD Curriculum
Executive Functions
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Executive Function

• What is executive function?
• Brain mechanisms that control goal-directed
  behavior
• Goal Directed Behavior Involves
• Visualizing situation
• Identifying desired objective
• Determining plan to meet objective
• Monitoring progress to goal
• Inhibiting distractions
• These are all behaviors, not brain mechanisms,
  and they can all be taught, just like any other
  behavior

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Executive Functions
Flexibility/ Set-Shifting Shades of
Gray Nonsocial Set-Shifting Social
Set-Shifting Social Cognitive Set-Shifting
Inhibition Waiting Physical / Motor Vocal Pencil
/ Paper
Inhibition
Flexibility

Attention Stimulus Orienting Disengagement Joint
Attention Determining Saliency Paraphrasing Summar
izing Sustained Attention Divided
Attention Alternating Attention
Planning Self-Organization Task / Social Goal
Setting Previewing Using a Planner Organizing
Materials Task Initiation Monitoring Progress
Attention
EF
Memory Visual Memory Auditory Memory Associative
Memory Working Memory Episodic Memory
Metacognition Self-Awareness Metamemory Emotion
Control Self-Management
Problem- Solving Simple Nonsocial Social
Memory
Problem- Solving
Meta- Cognition
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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive Skills
Play
Language
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Conclusion

• ABA is the only treatment for autism that has
  substantial science evidence for causing large
  improvements in children
• ABA programs should be comprehensive
• 25 or more hours per week of one-to-one
• Address all skills areas
• Two years or more of treatment
• Verbal behavior
• Generalization
• DTT
• NET
• Top-quality supervision