Bryna Siegel, Ph.D. Director, Autism Clinic

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• Bryna Siegel, Ph.D.Director, Autism Clinic
• Bryna.siegel_at_ucsf.edu
• Professor, Child Adolescent PsychiatryChildren
  s Center at Langley Porter
• University of California, San Francisco

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Give a man a fish and hell eat for a day

• Give a man a fishing pole and he will eat for a
  life time

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WHAT IS JUMPSTART? A NEW KIND OF EARLY
INTERVENTION

• FOR THE CHILD
• A Learning-to-Learn Program
• FOR THE PARENT
• A Parent-Centered Program
• Didactics
• Skills for Special Parenting (Special Education)
• Being an Informed Consumer and Advocate

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Syndromes Autism and the Common Cold

• The Autistic Spectrum
• Social Isolation
• Low Interest in Peers
• Echolalic Speech
• Non-conversational
• Perseveration
• Poor Toy Play
• Odd Motor Movements

• The Common Cold
• Runny Nose
• Stuffed Sinuses
• Hacking Cough
• Sneezing
• Sore Throat
• Feverish
• Headache

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What Does This Mean For Epidemiology? (When is a
sneeze a cold?)The Latest from the CDC

• 2007
• 6.71,000 1160
• 1 Language concerns, 2 Social
• Earlier Studies
• 1101 to 1222 (2000)
• 1303 to 194 (2002)
• 51-88 w/ signs
• 50 _at_ 4½-5½ years old

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Lets Just Treat Whats Wrong

• Importance (or Not) of Diagnosis
• Identifying Learning Processes
• Identification of What Needs to be Learned
• Figuring Out How to Teach so the Child becomes an
  Independent Learner

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How Social Deficits Affect Learning

• Lack of socio-emotional reciprocity
• Lack of desire to please others
• Low response to social reinforcers
• Lacks concern re effect on others
• Lack of awareness of others
• Motive to please self is foremost
• Instrumental learning style
• Lack of social imitation
• Low incidental learning via copying others
• No drive to follow group norms

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How Non-Verbal Communication Deficits Affect
Learning

• Low response to facial cues
• May not understand smiles of encouragement
• May not understand warnings of displeasure
• Ignores pointing, hand signals, head shakes that
  clarify words, control behavior
• Poor reception of non-verbal cues seen as
  non-compliance/ defiance
• Poor reception of non-verbal cues taken as
  inability to comprehend words/ voice tone

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How Verbal CommunicationDeficits Affect Learning

• Limitations in receptive language
• Signalnoise problem in incoming verbal
  signal
• -noisy social-linguistic field
• -limitations to pure memory buffer
• Language processing with poor parsing
• Limitations in expressive language
• Oral-motor apraxia has negative synergy w/ low
  expressive drive
• Without theory of mind, no drive to share
  ideas

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How Play and Exploration Deficits Affect Learning

• Lack of imagination in play
• No re-enactment of experience via play to link
  action and language
• No symbols to link to language to abstract
  thinking
• Stereotyped and repetitive interests
• Averse to novelty/ low curiosity
• Limited learning through exploration
• Repetitive interests mental down time

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Theoretical Underpinnings for JumpStart- I

• The Autistic Spectrum is a Collection of
  Autistic Learning Disabilities and Autistic
  Learning Styles Essentially Described by the
  Various DSM Diagnostic Criteria
• Each Criterion Met Specifies a Needed Area of
  Remediation and/or Delineates An Available or
  Non-Available Modality for Perceiving,
  Processing, Output of Stimuli

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Theoretical Underpinnings for JumpStart- IIThe
Developmental Perspective

• Evolution has worked out the most efficient
  sequence for skill acquisition (and supporting
  neural architecture).
• Developmental psychology maps that sequence.
• Children learn at different rates and in
  different ways, but the sequence of
  skills-building needs to be developmentally-ordere
  d to provide a solid foundation.

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Introducing JumpStart

• Intensive, one-week, parent training
• Center-based, two paired families per session
• Development of childs learning readiness skills
  so parents can wrap-around at home
• Focus on helping families learning skills to
  parent a child with autism
• Teaching parents to be discriminating consumers
  and general contractors

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JumpStart Goals for the Child

• Provide initial intervention for ASD children
  (mostly under 36 months)
• Develop learning readiness so the child can
  benefit from a wider range of educational and
  therapeutic resources
• Extended diagnostic period to develop on-going
  treatment plans based on individual learning
  strengths and weaknesses, and motivational profile

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JumpStart Goals for the Family

• Train parents to use a fishing pole, not just
  eat fish
• Introduce parents to modes of treatment
• Promote communication about autism (mother ?
  father, parents ?siblings)
• Encourage familys non-autism well-being
• Facilitate entry into appropriate on-going
  services

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JumpStart Goals of Training

• Teach parents to think like a teacher
• Teach parents to make home an autism-specific
  learning environment
• Train treators how this child learns for
  transition to on-going service, e.g.,
• Program specialists, School psychologists,
• Special day class, RSP inclusion teachers
• ABA tutors and other para-professionals.

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JumpStart Longer Term Goals

• Empirically test a model for earliest
  intervention centered on parent-training
• Become a community center for education and
  treatment of children with autism
• Reduce the distress associated with parenting a
  child with autism
• Create more informed consumers of autism services

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JumpStart Program Activities
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JumpStart Daily Parent Teaching

• All Days Direct parent didactics on autism
• Days 1-4 Observation through video 1-way
  mirror
• Watch Master Teacher, Review, Analyze Copy
  Master Teacher Self-Critique
• Days 3-4 Cross-teach another child
• Day 5 Docenting Observe future treators

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JumpStart Psycho-social Parent Intervention
Methods

• Group sessions for parents/ Topics
• Grief responses to the diagnosis
• Impact on the marriage and family
• Impact on individual life goals
• Parent pairings for social support

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The Child-Focused ProgramThree Tracks

• Cognitive Learning Readiness
• Motivation, Cause Effect, Pivotal Response
• Communication Foundations
• VIA (Visual Interaction Augmentation)
• Learning Through Child-Led Play
• Increasing Reciprocity and Expanding Repertoire

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I Developmental-Behavioral Approach

• Compliance and Attention
• Developing an Instructional Contract
• Expanding Reinforcers 1o Social
• Motivation
• Developing A Reward Hierarchy
• Moving Toward Naturalistic/ Contextual
  Reinforcers (a la PRT)

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Teaching That Is Developmental and Behavioral

• Based on where the child is developmentally (e.g.
  18 month receptive language)teach the next set
  of skills.
• Do teach using validated behavioral principles.
  (Dont teach from a cookbook dog-training
  manual).
• Teach the child according to needs and interest
  to establish parent as source of learningjust
  like any child.

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II Communication Foundations

• VIA Is About
• Communication Based on a Developmental
  Psycholinguistics Model of Habilitation
• Teaching Paralinguistics
• Teaching with Augmentative Visuals
• VIAs Goal
• Increasing Drive to Communicate
• Increasing Spontaneity/ Initiative

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III Learning Through Child-Led Play

• Increasing Reciprocity
• A la DIR, Expanding Circles/ RDI
• Expanding Repertoire
• Increase Curiosity/ Increase Exploration
• Decrease Behaviors Incompatible with Learning
• Scaffolding Sensory Threshold Problems
• Decrease Repetitiveness/ Rigidity

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The Parent-Centered ProgramThree Tracks
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I Didactics Learning About Autism and Autism
Treatments

• What Autism Is
• What We Know Now/ What We Might Learn/ Crystal
  Ball Readings
• Teaching How Children with Autism Learn
• The ALD/ALS Model
• Teaching What the Treatment Models Are
• Pre Fixe vs Al a Carte Dining
• Vaccinating Parents Against False Hope

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II Wrap Around Special Parenting The
Flip-Side of Special Education

• Learning Which Strategies Are Effective
• Observing Learning/ Reading the Child
• What the Child Apprehends/ Misapprehends
• How to Implement The Home Edition of Txs
• Developmental-Behavioral Teaching
• Learning to Communicate
• Mining the Value of Play

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III Dealing Proactively w/ Professionals

• Being An Active Participant in
• Private speech and language therapy
• Occupational therapy
• Play Based Therapy
• Its Not How Many Hours? Content Over Form
• Advocacy with Systems of Care
• The Regional Center
• The Schools
• Doctors and Other Professionals

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Four Special Emphases in JumpStart

• Establishing the Instructional Contract
• Areas of Child Instruction
• Pivotal Responding the Self-Initiating Learner
• Steps to Self-Initiated Learning
• Developmentally-Based Pre-Linguistic
  Communication Training
• VIA (Visual Interaction Augmentation)
• Applying the ALD/ALS (Autistic Learning
  Disability/ Autistic Learn Styles) Model

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1 JumpStart Cause and Effect

• Assessing the Instructional Contract
• Teach Do Something to Get Something
• Provide High Predictability
• Limit-setting
• Motor-prompting
• Repetition
• Visuals/ Visual Scheduling

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2-JumpStart Motivation

• First Assess Reinforcer Hierarchy
• Foods/ Sensory Rewards/ Activities
• Second DTT with external reinforcers
• Third PRT w/ intrinsic reinforcers
• Fourth Titrate Reinforcement Schedule by Task
  Difficulty
• Fifth Dont Let Data Get in the Way

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Principles of Pivotal Response Training
Incidental Teaching (Natural opportunities)
Mand- Model (Request- prompt)
Time- Delay (Wait for child)
Milieu Teaching (Combines all 3)
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3-JumpStart Self-initiated Learning

• First Non-verbal imitation training
• Second Opportunities to model high value events
  (incidental learning)
• Third Play turn-taking with high value
  activities
• Fourth Play elaboration based on intrinsic
  reward value of initial activity

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4-JumpStart/ VIAThree Key Communicative
Competencies

• Addressing Para-linguistic Deficits
• Pair non-verbal communication with visuals
• Pair vocal tone with visual cuing
• Addressing Theory of Mind and Central Coherence
  Deficits
• Teach to what the child has in mind
• Start teach w/ many specifics, not general
• Teaching Language Developmentally

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VIA Mechanics

• Photographic (or 3-D) icons only
• Photos of exactly what the child has in mind
• Icons with words labels to promote auditory
  recognition
• Icons located when and where the child has the
  object or action in mind
• Orally Speak motherese
• Gesturally Motherese para-linguistics

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VIAContrast with Teaching Verbal Behavior

• Teach semantics in developmental sequence
  (horizontally, not vertically)
• Teach multiple SDs, not multiple words in a set
• Why? To develop central coherence/ linguistic
  prototypes
• Teach concepts across natural contexts so
  generalization is not an extra step

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JumpStart/ VIARationale

• Developmentally-based acquisition of language
  concepts
• Emphasizes teaching integrated para-linguistics
  as foundational to linguistics
• Developmentally focused on increasing spontaneity
  over MLU or speech clarity
• Focused on increasing inter-subjectivity by
  sharing of desired object of communication

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JumpStart Research Component-IOverall
Treatment Model Efficacy

• Pre-test children at time of diagnosis
• Symptoms/ severity (DSM, ADI-R, ADOS)
• Language and Cognition (PLS, M-P, WPPSI)
• Social and language pragmatics (CSBS)
• Post-test after Jump Start
• Post-test after 6m 12m compared to
  treatment-as-usual (EIBI or SDC)

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JumpStart Research Component-IIVIA vs PECS

• Efficacy of a behavioral model for visually-based
  augmentative communication v a visual-developmenta
  lly based model
• Manual development
• Small RCT of VIA v PECS
• H VIA
• Language pragmatics
• Spontaneous requesting

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JumpStart Research Component-IIIDevelopmental
DT v DT as Usual

• Teach linguistic prototypes, not verbal SDs
• Periodic data, not trial-by-trial data
• Build in more child choice
• Dynamically inter-leaf adult-led and
  child-initiated trials by consistently
  reinforcing lead-taking by child

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References

• Siegel, B (2003). Helping Children with Autism
  Learn Treatment Approaches for Parents and
  Professionals, New York Oxford University
  Press.
• Siegel, B (1996). The World of the Autistic
  Child Understanding and Treating Autistic
  Spectrum Disorders, New York Oxford University
  Press.