The CARD Program: An application of behavior analysis to the treatment of autism

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The CARD Program An application of behavior
analysis to the treatment of autism
Center for Autism and Related Disorders, Inc
Doreen Granpeesheh, Ph.D. B.C.B.A Autism One
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Todays Presentation

• Kids with Autism DO recover
• Data
• Video
• Good ABA works
• What is good ABA
• The CARD program
• ABA works better with good biomedical
  interventions

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Pre-Post 3-year CARD Intervention

• N13 (12 boys, 1 girl)
• Mean age at enrollment
• 42 months (3.4 years)
• Range 37-48 months
• Method
• All children were given WPPSI or WISC at Pre- and
  Post- 3 year ABA early intervention

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Normal Cognitive Functioning
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CARD Post-Intervention Results

• 7 of 13 (53.8) no longer had ASD diagnosis
• 6 of 13 (46.2) went from Autism to PDD or
  Aspergers
• Average IQ score gain of 20.5 points
• 7-28 points in the literature (Smith, 1999)
• Recovered children received an average of 34
  hours of therapy
• Gained an average of 27.7 points on Wechsler
• ASD children received an average of 26 hours of
  therapy
• Gained an average of 12.2 points on Wechsler

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What is good ABA? What is ABA?

• ABA is based on the principles of
• Operant Conditioning Theory
• Human Behavior is affected by events that
  precede it (antecedents) and events that follow
  it (consequences)
• Change these eventschange Behavior!

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What behaviors do we want to change in Autism?

• Deficits
• Language
• Play
• Social Skills
• Cognitive Skills
• Executive Functions

• Excesses
• Self Stimulatory Behs
• Maladaptive Behs
• Tantrums
• Aggression
• Noncompliance

Skill Repertoire Instruction
Behavior Management
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Have you ever thought why your child has these
behaviors?

• Why didnt my child learn to speak?
• Why does my child avoid eye contact?
• Why cant my child pay attention?
• Why does my child line up his toys instead of
  playing with them?
• Why does my child tantrum so much?
• Why does my child get so upset when his routine
  or ritual is disturbed?

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Behaviors that he doesnt do enough of

• Language
• Play
• Social Skills
• Cognitive Skills
• Executive Functioning Skills
• Why are these skills deficient in children with
  Autism?

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Can biology lead to behavior?

• Autism
• Immune dysfunction
• GI dysfunction
• Abnormal chemistry
• How does all this affect the developing brain of
  a child?

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The Brain Is Involved In Everything You Do

• Who you are as a...
• parent
• child
• student
• friend

• How you...
• think
• feel
• act
• interact

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• When your brain works right, you work right

• When your brain doesnt work right, you cant
  work right

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Prefrontal Cortex Functions

• Focus
• Forethought
• Impulse Control
• Organization
• Planning
• Judgment
• Empathy
• Insight

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Prefrontal Cortex Problems

• Short attn span
• Impulsivity
• Procrastination
• Disorganization
• Poor judgment
• Lack of empathy and insight

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CINGULATE GYRUS

• Gear Shifter/Integration

• Posterior Part
• Memory Integration
• Ant. Dorsal Part
• Thought Shifting
• Ant. Ventral Part
• Emotional shifting

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Anterior Cingulate Function

• Cognitive flexibility
• Shift attention
• Go from idea to idea
• See options
• Go with the flow
• Cooperation

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Anterior Cingulate Problems

• Gets stuck
• Worries
• Holds grudges
• Obsesses
• Compulsions
• Addictions
• Oppositional/argumentative

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Why are children with autism deficient in some
skills?

• Their brains are not developing in certain areas!
  
• Why early intervention?
• Because the brain can learn to compensate and
  develop when its young!

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Can we teach all these skills?

• Can we teach
• Attention
• Memory
• Motivation
• Planning
• Inhibition
• Flexibility
• Sure we can! Look at our Cognition and EF
  curricula!

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Behaviors that my child does too often.

• Tantrums
• Aggression
• Self injurious behavior
• Self stimulatory behavior
• Why are these behaviors excessive in children
  with autism?
• Behavior analysis tells us challenging behaviors
  occur because there is no other type of
  communication
• Everything we do is either to get good stuff or
  avoid bad stuff
• If the child could communicate, he wouldnt act
  out!

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Challenging Behavior

• Example getting good stuff

Jenny is playing with her favorite toy. Parent
says okay, time to put away the toy
Parent lets Jenny have the toy a little longer
Jenny starts whining
How is this like language? What is Jenny saying
by whining? How about I dont want to put my toy
away, can I play a little longer? Can we teach
her to say that?
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Challenging Behavior

• Example avoiding bad stuff

Jacob hates baths. Parent says Time to take a
bath
Jacob cries and throws himself on the floor
Jacob gets to avoid the bath for five more minutes
How is this like language? What is Jacob saying
by crying and throwing himself on the floor? How
about Can I have five more minutes Mom? Can we
teach him to ask for more time?
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Challenging Behavior

• Example getting good stuff AND avoiding bad
  stuff

Johnny is playing outside. Parent says Time to
come inside and clean your room
Johnny gets to play outside a little longer AND
doesnt have to clean his room yet
Johnny runs away
How is this like language? What is Johnny saying
by running away? How about I want to keep
playing AND I dont want to clean my room Can we
teach him to say that instead?
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Dealing with challenging behaviors

• If we teach appropriate communication skills,
  they will replace challenging behaviors in our
  kids
• Challenging behaviors are NOT part of the Autism
  diagnosis! They are just a side effect!

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What makes a good ABA provider?

• Someone who believes children with autism do
  recover!
• Someone who really understands why your child
  functions the way he does
• Understands how the brain impacts behavior
• Understands how behavior is learned over time
• Someone who can teach your child the skills he
  needsskills he didnt learn when he was younger.
  

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The CARD I Treatment Model

• ABA Foundation
• Errorless Teaching
• Discrete Trial Training
• Natural Environment Training
• Fluency
• Verbal Behavior throughout instruction
• Children from 0-8 yrs
• Intensive treatment
• Shift from home-based 11 learning to school
  community based learning opportunities
• Biological Intervention

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Assessment

• - What are my childs exact
• skills and deficits?
• -You need to assess in all areas of functioning!

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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive
Play
Language
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The CARD Curriculum
Language
By Emerging Age and Verbal Operant

• 0-11 mos.
• Body Parts
• Following Instructions
• Gestures
• Making Requests
• People
• Sound Discrimination
• Verbal Imitation
• Yes/No
• 10 111 yrs.
• Actions
• Asking for Information
• Categories

• Choices
• Fast Mapping
• Functions
• Objects
• Opposites
• Prepositions
• Pronouns
• 20-211 yrs.
• Adverbs
• Attribute-Object
• Conditionality
• Deliver a Message
• Features
• Gender
• I Have/ISee

• Listen to/Tell a Story
• Locations
• Negation
• Plurals
• Recalling Events
• Sound Speed Duration
• Syllable Segmentation
• Wh-Discrimination
• 30-311 yrs.
• Minimal Pairs
• Same/Different
• Sequences
• Sound Changes

• Statement-Statement
• 40-411 yrs.
• Describe by Category/Feature/
• Function
• Phonic Same/ Different
• Statement- Question
• What Goes With
• 50-511 yrs.
• Observational Learning
• Syntax

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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive
Play
Language
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The CARD Curriculum
Play

• Features of a Comprehensive Play Skills Program
• Modeled after the development of play skills in
  typically developing children
• Breaks down each type of play into its own
  systematic and comprehensive program
• Sequential format
• Programs may be used individually, concurrently,
  or cumulatively

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The CARD Curriculum
Play
Target Areas
Independent Play Tracking
Block Imitation Structure Building Sand
Constructions Clay Constructions Arts and Crafts
Constructive Play
Social Emotional Development through Play
Independent Vocal Play Reciprocal Vocal
Play Exploratory Play
Functional Pretend Play Symbolic Play Imaginary
Play Sociodramatic Play
Pretend Play
Social Games Nursery Rhymes Songs with
Objects Board Games Locomotor Play Peer Play
Independent Toy Play
Interactive Play
Sensorimotor Play Task Completion (Peg Boards,
Puzzles)
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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive
Play
Language
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The CARD Curriculum
Adaptive Skills
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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive
Play
Language
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Motor Skills
The CARD Curriculum
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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive
Play
Language
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The CARD Curriculum
School Skills
Math Number Concepts Rote Counting Reading
Numerals Numeral Comprehension Ordinal
Position Numerals in Sequence Addition Subtraction
Advanced Counting Money Time
NonAcademic Skills
Physical Education
Language Arts 1 Reading Visual Discrimination of
Symbols Reciting Alphabet Uppercase
Letters Lowercase Letters Word Recognition Reading
Orally Reading Comprehension Book
Topography Story Comprehension Story
Summarizing Text Comprehension
Language Arts 2 Manuscript Writing Printing
Symbols Personal Data Lowercase Letters Uppercase
Letters Letters in Sequence Letters Dictated
Simple Sentences Quality of Printing
Science
History Social Studies
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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive
Play
Language
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The CARD Curriculum
Cognition

• Cognition
• Meta-cognition Identifying your own
• Social Cognition Inferring others
• Emotions
• Thoughts
• Knowledge
• Desires
• Beliefs
• Intentions

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Cognition
Classic Test of Social Cognition Sally-Anne or
False-Belief Task
Where will Sally look for her ball? Where does
she think her ball is?
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Cognition
Typical Meta and Social Cognitive
Development First few months Sense of Self 9
months Joint Attention / Social
Referencing 15 months Pretence 18 months
Desire / Intention 2 years Emotion 3
years Knowing / Thinking 4 years Belief /
False-Belief 5 years Intention Accident vs.
Purpose
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The CARD Curriculum
Cognition
10 Target Areas
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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive
Play
Language
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The CARD Curriculum
Social Skills
Social Interaction Apologizing Assertiveness Compl
iments Cooperating Negotiating Gaining
Attention Greetings and Introductions Levels of
Friendship Relationships/Manners Requesting
Cessation Sharing/Turn Taking
Social Language Social Vocalization Topic
Selection Topic Initiation Topic
Maintenance Topic Breakdown and Repair Topic
Transitioning Joining a Conversation Ending a
Conversation Prosody
Absurdities Figures of Speech Humor and
Jokes Tricks and Deception
Self Esteem Dealing with Conflict Wishes Positive
Self Statements Winning Losing
Group Related Skills Choral Activities Group
Discussion Peer Pressure
Social Context Community Social
Behavior Imitation Responding to Social
Cues Whats Missing Inferences
Social Rules Compliance Recognizing
Rules Following Rules Questioning Rules
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The CARD Curriculum
School Skills
Executive Functions
Cognition
Social Skills
Motor Skills
Adaptive
Play
Language
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The CARD Curriculum
Executive Functions
What is Executive Function?

• Process that underlies goal directed behavior
• Goal Directed Behavior Involves
• Visualizing situation
• Identifying desired objective
• Determining plan to meet objective
• Monitoring progress to goal
• Inhibiting distractions

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The CARD Curriculum
Executive Function
Basic EF Concepts Eye contact Pointing Joint
Attention
Social Planning Planning in social contexts
Basic Concepts
Fexibility Generating Alternatives Problem
Solving Relaxation Training

Social Planning
Flexibility
Task Planning Organizing Materials Prioritization
Time management Goal Direction Task Initiation
Attention Cognitive Set Shifting Sustained
Attention Divided Attention Alternating
Attention Saliency
Attention
EF
Meta-Cognitive Self-Evaluation Self-Monitoring
Of Attention Of Reinforcement Emotion
Regulation
Memory Working Visual-spacial Auditory Associative
Meta- Cognitive Planning
Memory
Inhibition Waiting Generating Alternatives Identif
ying social cues
Inhibition
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A 4 year progression

• Year 1
• Child entering at age 2-3
• 25 hours per week building to 40 hours
• Emphasis on
• Building a relationship with child
• Replacing challenging behaviors with functional
  communication
• Mands (Requests)
• Tacts (labels)
• Receptive identification (objects, actions, body
  parts, colors, shapes)
• Receptive instructions
• Verbal and Non-verbal Imitation
• Identical Matching
• Play Skills (toy play)
• Adaptive Skills (toilet training)
• Fine and Gross Motor
• Dietary restrictions/medical compliance

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A 4 year progression

• Year 2
• Child age 3-4
• 40 hours (in home with partial transition to
  school)
• Emphasis on
• Building Expressive Language
• Objects, Actions, Attributes, Prepositions,
  Pronouns
• Categories, Functions, Occupations, Locations
• Beginning Conversation
• Intraverbals
• Reciprocal Statements
• Asking Questions
• Developing Observational Learning
• I See
• Sequences
• Tell me about/Describe
• Emotion Recognition
• Inferring others desires
• Play Skills (functional pretend, symbolic,
  imaginary)

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A 4 year progression

• Year 3
• Child age 4-5
• 40 hours (20 hours at home 20 hours at school)
• Sample Programs
• Advanced Language Concepts
• Pragmatic Language
• Maintaining Conversation (topic initiation,
  repair, maintenance)
• Meta and Social Cognition
• Identifying and Managing own emotions
• Understanding others Perspectives, Knowledge
• and Beliefs
• Inferences
• Executive Function
• Attention Saliency
• Flexibility with Routines
• Inhibition and Self Monitoring
• Planning
• Social Skills
• Levels of Friendship

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A 4 year progression

• Year 4
• Child age 5-6
• 40 hours (10 hours at home 30 hours in school
  and fading services)
• Emphasis on
• Teacher and Parent training
• School Skills
• Listening and Reading comprehension
• Math and Problem Solving
• Advanced Social Skills
• Detecting Sarcasm
• Understanding Deception
• Group Skills
• Continued Self Regulation
• Self Esteem and Confidence
• Task and Social Planning

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What makes a good ABA provider?

• Someone who believes children with autism do
  recover!
• Someone who really understands why your child
  functions the way he does
• Understands how the brain impacts behavior
• Understands how behavior is learned over time
• Someone who can teach your child
• Skills (core skills and processing skills)
• Has an assessment
• Has a curriculum
• Techniques to compensate for difficult areas
• Techniques to reduce anxiety
• Someone who believes that Autism is a medical
  disorder that requires medical intervention

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Biomed and ABA?

• Biological Treatment
• Eliminate Triggers
• Stabilize condition
• Achieve Health
• Ensure the childs Maximum Learning Potential

• ABA
• Increase Skills
• Decrease Maladaptive Behaviors
• Generalize to Daily Living

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A healthy child..

• Eats better
• Sleeps better
• Feels better

• CAN LEARN BETTER..

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ABA and Biomedical together
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New Skills Acquired
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Behaviors Reduced