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Best Practices in Screening, Assessment and Intervention for Children with Autism Spectrum Disorders


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Title: Best Practices in Screening, Assessment and Intervention for Children with Autism Spectrum Disorders

Best Practices in Screening, Assessment and
Intervention for Children with Autism Spectrum
  • Susan L. Hepburn, Ph.D.
  • University of Colorado at Denver and Health
  • Juneau, Fairbanks, and Anchorage, Alaska
  • March 2008

The Autism Spectrum
  • Similarities Difficulties in 3 areas
  • Social functioning
  • Communication/language
  • Restricted activities and interests

Possible Differences Amongst Kids with an ASD
  • Level of cognitive functioning
  • Presence/absence of spoken language
  • Severity of symptoms
  • Specific behavioral expression of symptoms
  • Chronological age
  • Temperament or behavioral style
  • Vulnerability to other conditions, such as
    attentional, anxiety or mood issues

Social Style
  • Aloof
  • Passive
  • Active-But-Odd

Social Style and Goals
Aloof ? Responding Passive ? Initiating
Active-But-Odd ? Reciprocity
Children with different styles require different
educational approaches
Developmental Aspects of Autism
  • Symptoms are qualitatively different at different
    stages of development

Developmental Model of Autism
Moderating Features
Social/Communicative Functioning
Associated Features
To elaborate....
  • Core features (1) Social-communicative
    functioning and (2) ability to adapt
  • (or modify behavior in response to changes in
    context in a fluid manner)
  • Moderating features (1) cognitive ability, (2)
    language ability, (3) behavioral style
  • Associated features (1) attention, (2) anxiety,
    (3) mood, (4) problem behaviors

Best practice developmentally-
informed practice
  • Screening
  • Assessment
  • Intervention

Always considering an individual childs core
symptoms of autism, moderating factors, and
associated features
Focus of Todays Talk
  • What do we know about autism across development
    in childhood and adolescence?
  • And what does our developmental knowledge tell us
    about what we should be doing?
  • Screening
  • Assessment
  • Intervention

Studying Autism in Infancy
  • Retrospective videotape analysis
  • See reviews by Charman (2000) and Rogers (2001)
    Werner et al (2000)
  • Record review
  • e.g., Johnson, Siddons, Frith, Morton (1992)
  • Prospective sibling studies
  • e.g., Zweigenbaum et al (2005) Landa et al.
    (2005) Rogers et al.(2005)

Possible Symptoms in Infancy
  • Deficits in dyadic person-to-person -social
  • Baby is out of sync with caregivers
  • Lack of social smile
  • Delayed response to name
  • Unusual affect
  • Lack of appropriate facial expressions
  • Adrien et al, (1993) Baranek (1999) Rogers

Possible Symptoms in Infancy (cont.)
  • Signs of central nervous system dysfunction
  • Hypotonia
  • Lack of appropriate facial expressions
  • Abnormalities in orientation to visual stimuli
  • Aversion to touch
  • Signs of poor frontal lobe development
  • Poor integration of verbal and nonverbal
  • Poor attention
  • Adrien et al, (1993) Baranek (1999) Ozonoff et
    al (2007)

In summary, the results of infant studies suggest
that abnormalities are
  • Subtle
  • More likely to involve the absence of rich social
    behaviors and not the presence of unusual
  • Qualitative
  • A matter of reduced frequency, not complete
    absence (Charman et al, 1997)
  • Inconsistent Presence of intact behavior
    sometimes does not mean everything is okay
    (Charman et al, 1998)

Absolute Indicators for a Developmental
Evaluation from Birth to 3 Years
  • No babbling by 12 months
  • No gesturing by 12 months
  • No single words by 16 months
  • No 2-word spontaneous phrases by 24 months
  • Any loss of any language or social skills at any

American Academy of Pediatrics, 2005 Centers for
Disease Control, 2006
Characteristics of Autism at Young Ages
  • Toddlerhood (18 36 months)

Best Discriminators of Autism between 18 months
and 3 years of age
  • Social and communicative impairments
  • Less likely look at others
  • Less likely to show objects
  • Less likely to point to an object
  • Less likely to orient to name
  • Less likely to follow attention
  • Overall lack of social orienting
  • (Charman Baird, 2002 Cox et al, 1999
    Osterling Dawson, 1994 Mundy et al, 1994
    Stone, Hoffman, Lewis, Ousley, 1994 Stone,
    Ousley Coonrod, 2005)

  • Parents of young children report general behavior
    problems, with few reports of social difficulties
    (Charman Baird, 2002)
  • Parents of young children notice unusual
    responses to sensation (Baranek, Foster,
    Berkson, 1997)
  • Regression of communication skills occurs in
    approximately 15-30 of cases
  • (Filipek et al, 1989)

By 30 months, many children with autism can
  • Follow an adults attention (i.e., respond to
    joint attention Mundy et al, 1994)
  • Indicate a simple request without coordinated
    eye contact usually requesting improves in
    complexity by age 3 (DiLavore Lord, 1995)
  • Communicate to get access to objects, but not to
    get an adults attention Stone et al, 1997)
  • However, requesting behavior in autism rarely
    includes coordinated eye gaze, gesture, and/or
    vocalizations (Stone et al, 1997)
  • Manipulate another persons hand like a tool to
    send a message (Stone et al, 1997)

Characteristics of Autism at Young Ages
  • Preschool Years (3 5 years)

Discriminating Items on Screening Tools for
Preschool-aged Children (3 5 years)
  • Rarely performs simple actions with a doll
  • Rarely engages in pretend play
  • Rarely integrates gestures and/or eye gaze with
    attempts to communicate
  • May respond better to an adults bid for
    attention, but still has trouble with initiating
    joint attention
  • Fewer shows and points to share attention
  • Imitation is not spontaneous, and/or is often of
    poor quality

Robins et al, 2002 Stone et al, 2005 Wetherby
Woods, 2004
Compared to Typical Development
  • Remarkably, typically-developing children do many
    of the behaviors lacking in 4-year olds with
    autism by the end of their first or second years
    of life
  • (Carpenter, Nagell, Tomasello, 1998 Fenson et
    al, 1994)
  • These behaviors are associated with word learning
    (Tomasello, 2001)
  • And social understanding (Charman et al, 2000)

Autism Vs.
  • Any impairment in social or communicative
    behavior seems consistent with the childs
    mental age
  • Development is evenly delayed few splinter
  • (Lord Pickles, 1996)
  • Lack of social interest
  • Limited use of pointing
  • Poor nonverbal communication
  • Poor imitation skills
  • Limited pretend play
  • RELATIVE to overall developmental level

Characteristics of Autism at School Age
  • Elementary Years (6 11 years)
  • Middle School Years (11 14 years)
  • High School Years (14 18 years)
  • Transition/Young Adulthood (19 22)

Developmental Challenges During Elementary Years
  • Play gets more cooperative
  • Social groups form (in and out)
  • Planning and other executive function skills
    become more important
  • Social demands for conformity increase
  • Social relationships are more complex
  • Increased reliance on nonverbal cues and subtlety
    of social signals
  • May be more self-awareness of differences,
    particularly around the 3rd grade

Around Puberty.
  • Some children become more anxious
  • Some become a bit overwhelmed by the
    organizational demands of middle school
  • Some show some problem behaviors that havent
    shown for a long time
  • Some have questions about social rules and
    boundaries and need some psychoeducation
  • Important time to monitor for overall well-being

Quality of Life for Teenagers
  • Does he/she have a favorite activity or passion
    and are there opportunities to enjoy this often?
  • Are there chances to spend time with other kids
    of similar ages and interests?
  • Is there a chance to get exercise and have time
  • Are there expectations for taking personal
    responsibility at home and at school?

Critical Issues of Late Adolescence (Ozonoff et
al., 2002)
  • Finding support people other than parents
  • Disclosure
  • Sexual development
  • Romantic relationships
  • Identity Development
  • Depression and anxiety
  • Seizures or other neurological symptoms (e.g.,

Implications for Screening
  • Across childhood and adolescence

Essential Elements of Screening
  • Developmental history (e.g., milestones, first
  • Medical history
  • Family history
  • Cognitive/developmental assessment
  • Needs to include interview and observation

Best Practice in Screening
  • If you hear concerns about nonverbal
    social-communication behavior linked with
    concerns about rigidity refer for screening
  • Gather both parent report and direct observation
  • Integrate observations from a multidisciplinary
  • Directly assess social reciprocity
  • (Charman Baird, 2002 Filipek et al,
    1999 Lord Risi, 1999 Rogers, 2001 Sandler et
    al, 2001)

Best Practice (cont.)
  • Obtain information from unstructured situations
  • Consider the childs access to social experience
  • Clinicians should seek training on
    semi-structured interviews to expand their
    knowledge of autism at different levels of
    development even if they dont use them all the
  • (Charman Baird, 2002 Filipek et al, 1999 Lord
    Risi, 1999 Rogers, 2001 Sandler et al, 2001)

Best Practice (cont.)
  • Include a medical and developmental history
  • Provide various types of social presses in
    interaction with child
  • (Charman Baird, 2002 Filipek et al, 1999 Lord
    Risi, 1999 Rogers, 2001 Sandler et al, 2001)

Consider the known genetic risks
  • 5 of families with a child on the autism
    spectrum will have another
  • This translates to 5 in 100, or 50 in 1000
  • Typical rate is 1 in 1000
  • Risk increases from 1 to 50 per 1000
  • Or.
  • If you have a child with autism, you have a
    19-out-of-20 chance that a future child will not
    be autistic
  • Keep in mind... The risk of having a second child
    with some features (but not the whole picture) is
    thought to be higher
  • (LeCouteur et al., 1996 Rutter et al, 1996
    Szatmari, Jones, Zwaigenbaum, MacLean, 1998)

Challenges of Screening for Autism in Young
  • Autism can occur with other conditions
  • Hard to know how good the standardized tools are
    for early identification
  • Reliability of early diagnosis is still being
  • It is still difficult to predict prognosis
  • (Charman Baird, 2002)

Remember how different the picture can look in
young children (Dixon et al., 2005)
  • Majority of toddlers with autism do NOT display
    the following DSM-IV symptoms
  • Impaired conversation
  • Adherence to routine
  • Stereotyped language
  • Restricted interests
  • Preoccupations with parts of objects

Screening Instruments for Young Children
  • Within the general population
  • Checklist for Autism in Toddlers (CHAT Baird et
    al, 2000 Baron-Cohen et al, 2000)
  • Within a clinically-referred population
  • Modified CHAT (M-CHAT Robin et al, 2001)
  • Screening for Autism in Toddlers (STAT Stone,
    Coonrod, Ousley, 2000
  • Pervasive Developmental Disorders Screening Test
    (PDDST Siegel, 1999)

New Screening Tools for Young Children
  • STAT scoring system for children between 12-24
    months (Stone et al., 2005)
  • First year Inventory (FYI) (Watson et al.
    2005)screening 12 month olds in general
    population for risk of ASD
  • Language impairments in ASD (Zwaigenbaum et al.
    2005) less vocalization overall and more
    atypical vocalizations
  • AOSI (Bryson et al, 2007) development of
    instrument to measure autistic behaviors in very
    young children (beginning at 6 months)

Why screen after age 5?
  • Some bright children, particularly those who are
    not high in activity level, may not be identified
    in the preschool years
  • The impact of having high-functioning autism can
    hit harder after preschool and more kids need
  • Due to increase in organizational demands
  • Due to increase in abstract (not rote) material
    in 2nd-3rd grade
  • Due to decreased opportunities to learn
  • Some severely-impaired, developmentally delayed
    children are misdiagnosed with autism in
    preschool years, and SES factors may influence
    early identification process (Desposito, 2002)
  • A formal identification of an ASD can help to
    guide interventions and promote understanding of
    why the student behaves as he does
  • and communicate other times a needs-based
    approach, without a formal label, can be

Screening Tools for School-Aged Children
  • Social Communication Questionnaire (SCQ Lord et
    al., 2003) parent interview, very short version
    of ADI-R yes/no responses, best for children 5
    and older, score of 15 is at risk
  • Autism Behavior Checklist (Krug, 1989) Teacher
    or parent checklist, symptoms consistent with
    classic as opposed to atypical presentation, may
    over-identify kids with MR as having autism

Screening for high-functioning or atypical autism
  • Asperger Syndrome School Questionnaire (ASSQ
    Ehlers, et al., 1989) normed on several thousand
    school-aged children in Europe, being piloted in
    US through CADDRE project
  • Childrens Communication Checklist (Bishop et al,
    2003) teacher or parent checklist or interview
    that captures information on childs use of
    pragmatics (social communication)

Sample Questions from the ASSQ
  • can be with other children, but only on his/her
  • has clumsy or awkward movements or gestures
  • uses language freely, but fails to make
    adjustments for his listener
  • has a literal understanding of language
  • has difficulties completing daily routine

Implications for Assessment
  • Across childhood and adolescence

The Familys Experience with DiagnosisIs it a .
  • Hearing problem?
  • Language delay?
  • Global developmental delay?
  • Is it a general behavior problem?
  • Seizure disorder?
  • Genetic disorder
  • Metabolic or gastro-intestinal disorder?
  • Auto-immune disorder?
  • Go to the audiologist
  • Go to Child Find
  • Go to the speech pathologist
  • Go to a psychologist
  • Go to your pediatrician
  • Go to a neurologist
  • Go to a genetics clinic
  • Go to a GI doctor
  • Go to a nutritionist
  • Go to a DAN doctor

Areas of Assessment
  • Developmental/cognition/academics
  • Strengths, preferences, learning style
  • Play and social interaction
  • Communication, language, speech
  • Adaptive behavior
  • Fine/gross motor
  • Family functioning and resources

Developmental/Cognitive Assessments
  • Consider standardized measures that assess both
    verbal and nonverbal functioning
  • Preschool Mullen Scales of Early Learning or
  • Bayley Scales of
    Infant Development
  • Kindergarten Differential Abilities Scale,
  • Stanford-Binet-V, K-ABC,
  • Sometimes, examine nonverbal cognitive
    functioning more deeply (e.g., Leiter-R,
    Merrill-Palmer, Ravens Matrices, C-TONI)

Communication Skills
  • Range of communicative functions
  • Behavioral regulation
  • Coordinating joint attention
  • Ability to synthesize forms
  • Gestures
  • Eye gaze
  • Spontaneity of use
  • Social directedness of communication
  • Profile of receptive and expressive abilities

Language Skills
  • Receptive ability
  • Expressive ability
  • Pragmatic skills
  • Functional/spontaneous use of language on a daily
    basis (e.g., frequency and complexity)
  • Symbolic play

Speech Skills
  • Oral-motor integrity
  • Range of vocalizations
  • Spontaneity of vocalizations
  • Ability to imitate sounds or produce on cue
  • Volume, prosody, etc.

Adaptive Behavior Assessment
  • Scales of Independent Behavior - Revised (SIB-R
    Bruininks et al., 1996)
  • Vineland Adaptive Behavior Scales (Sparrow et al.
    1984 teacher and parent forms supplementary
    norms for autism)
  • AAMD Adaptive Behavior Scales (Lambert et al.,

Could the child have autism?First Step Parent
  • Presenting problems and concerns
  • Medical and developmental History
  • Social and family history family functioning and
  • Current interventions and therapies
  • Autism Diagnostic Interview Revised (Lord et al.,
  • social relatedness, communication, ritualistic
    behaviors gold standard, requires training

Parent/Caregiver Questionnaires about Social and
Communicative Development
  • Social Communication Questionnaire ages 4
  • (SCQ Berument et al, 1999)
  • Childhood Routines Questionnaire
  • (Evans et al, 1997)
  • MacArthur Communication Development Inventory
    best for young children or less verbal
    children(CDI Fenson et al, 1993 1994)
  • Social Responsivity Scale (SRS Constantino, 2001)

Direct Observation of Social and Communicative
  • Autism Diagnostic Observation Schedule (Lord et
    al, 1999) is a commonly used assessment tool that
    provides opportunities to observe subtle social
    and communicative behaviors
  • Developmentally sensitive
  • Can inform interventions
  • Can be used across the lifespan

Challenges Using the ADOS
  • Requires clinical experience with autism spectrum
  • Requires a lot of practice to administer and
  • Requires that you sit back and not
  • over-scaffold or do your job too well

Best Practice
  • Seek training through the University of Chicago
    or certified trainer and follow the recommended
    training protocol
  • Maintain a core group of staff to administer and
    co-score assessments
  • Practice regularly
  • Use in combination with other measures -
    Especially parent report
  • Know the limits and the strengths of the tool
  • Know how to talk to the parents about the results

Implications for Intervention
  • For Young Children

Cascade Theory (Rogers, Pennington, Loveland)
  • Maybe there are several early deficits that
    conspire to pull the child away from active
    involvement with the social world
  • And maybe this restricts their access to social
    learning, so that they miss out on learning
  • And maybe thats why some kids get worse and
    worse, and others get better and better

The key to outcome for children with autism might
  • Active engagement in the social world
  • Active involvement with peers and adults
  • Lots of practice with difficult social and
    communicative interactions
  • Consistent exposure to new situations
  • Persistence, even when its hard
  • Setting small goals and ensuring success

Which is best delivered through
  • Early intervention in an integrated, multifaceted
    intervention program
  • Developmentally-focused approach
  • Delivered in many different formats
  • 11 and highly structured
  • Natural routines and daily activities
  • For a review see National Council on Research,

Goals for Intervention with Young Children
  • Increase active engagement in social and
    communicative interactions
  • Teach in multiple real-life settings
  • Increase the opportunities for sharing attention
    and affect with the child with autism
  • Use routines and predictable, physical activities
  • Alternate following childs lead with leading the
  • Actively teach following and initiating joint
    attention, as well as imitation skills

Teaching Joint Attention (cont.)
  • Set up motivating activities that encourage
    attention and interest
  • Prompt the shared attention response and
    reinforce with continued activation of the toy
    (or another natural consequence)
  • Practice, practice, practice Kasari et al.
    (2004) are doing 10-minutes per day for 5 days a
    week and showing strong skill development in
    preschool children within 7 weeks

  • Imitation is the basis for cultural learning
  • Imitation ability is strongly influenced by ones
    ability to generalize
  • Imitation leads to language learning in typically
    developing children, as well as social-emotional

Implications for Intervention
  • For School-aged children

Overview of Interventions
  • Supporting the Master Planner of the Brain
  • Educational modifications
  • Minimizing interfering behaviors in the classroom
  • Improving social competence
  • Naturalistic or Peer-Mediated
  • Narrative or Cognitive-Behavioral
  • Direct Instruction

I. Supporting the Master Planner of the Brain
  • Helping with attention,
  • organization,
  • inhibition,
  • initiation, and
  • sustaining attention

3 Kinds of Attention Problems
  • Shifting attention
  • From own agenda to anothers agenda
  • From favorite topic to less preferred topic
  • From internal world to external world
  • From self to other
  • Sustaining attention
  • Short attention span
  • Tendency not to finish what has been started
  • Easily distractible
  • Missing the forest for the trees
  • Overly focused on details
  • Missing the big picture

Helping Children Shift Attention
  • Visual cues to focus attention
  • Advanced warning of shift in attention
  • Clear endpoints for activities
  • Routine for shifting attention
  • Practice attending to nonverbal cues

Helping Children Sustain Attention
  • Clear indication of how long attention should be
  • Provide frequent breaks
  • Reinforce/reward appropriate attending
  • Give them a task to do need some kind of active
    involvement in activity
  • Reduce distractors in the environment
  • Give directions 1 step at a time

Sustaining attention (cont.)
  • Consider seating the child towards the front of
    the classroom near good peer models
  • Be aware that too much auditory information
    without visuals is difficult to attend to for
    most of these kids
  • Give specific listening assignments (e.g., list
    of words to check off when heard)

Helping Children to Focus on the Whole as the Sum
of the Parts
  • Provide verbal and visual cues concerning the
    big picture
  • Highlight the most important concepts
  • Explicitly link main ideas and supporting ideas

Structured Teaching
  • Structured teaching examples were downloaded from
    the Wisconsin Department of Special Education
  • Stokes, S. (2005). Effective Programming for
    Young Children with Autism (Ages 3-5). Written
    by Susan Stokes under a contract with CESA 7 and
    funded by a discretionary grant from the
    Wisconsin Department of Public Instruction.  

Allow a headstart on transitions
  • Student may need more time to organize self for
    next activity
  • For some students, chaos of other children making
    a transition is overwhelming see if student can
    start earlier or later than other students
  • Whenever possible, reduce transitions
  • Use buddy system for room changes

II. Educational Modifications
  • Contributions by
  • Sally Ozonoff, Sue Thompson, Jennifer Stella

How to teach new concepts (Klin Volkmar, 2001)
  • Explicitly
  • Rote/rule-governed
  • Verbally (if Aspergers)
  • Visually (if High-functioning Autism)
  • Parts-to-wholes
  • Sequentially

If the child processes slowly
  • Avoid timed tests
  • Encourage completion provide visual cues for
    starting and stopping and require only enough
    work that child can finish with other students
    and experience closure
  • Require completion of part of assignment

If the child struggles with handwriting
  • Consider oral tests or projects instead of papers
  • Encourage typing assignments
  • Reduce amount of copying that must be done
  • Make sure worksheets have enough response space
    for large writing
  • Use multiple choice instead of fill in the blank
  • Emphasize quality, not quantity
  • See if child can purchase school books and
    highlight (instead of taking notes)

If the student has visual-spatial weaknesses that
make math difficult
  • May need visual cues to align numbers in math
    problems, use decimal points,dollar signs, etc.
  • Provide a step-by-step approach to solving
  • Encourage talking through word problems
  • Try to reduce amount of repetitive writing
  • Give an example of a completed assignment

Monitor for reading comprehension
  • Some students will become expert decoders
    without truly understanding what they are reading
  • Actively teach how to identify main ideas,
    supporting points, character perspectives, etc.
    Can be done in a rule-based approach.
  • Provide the student with the text the night
    before so that he/she can preview it

Be ready for parallel activities
  • If an activity is appropriate for the other
    students, but is likely to be frustrating for the
    student with HFA, consider designing a parallel
    activity that teaches the same concepts but in a
    different way. Allow students to choose which
    activity to do.

Use Computer-Based Instruction
  • Practice skills with educational software
  • Fast ForWord for phonological processing and
    other important literacy and language skills
  • Interactive CD-ROMs for narrative structure,
    science, math, special interests
  • Practice writing via email
  • Practice research via internet

Be careful about overwhelming the student with
  • Families often report that homework is a
    significant stressor
  • When giving homework, be sure to give complete
  • Whenever possible, provide study hall towards the
    end of the day with a tutor available to complete
  • Whenever possible, set a homework routine

Use an assignment notebook
  • Teacher takes the lead in monitoring its use
  • Student will need to be prompted to add/delete
  • Use existing systems that look normal
    Daytimer, etc.

Break assignments down into steps
  • Use clearly numbered sequences to illustrate
  • Webs or flowcharts might be useful
  • Actively involve student in monitoring completion
    of assignments

For large assignments
  • Show student how to break large tasks into steps
    and check-off when each step is completed
    observe completed steps, student may not report
  • Have regular meetings with student to monitor
  • Send written description of large assignments
    (with due dates and steps) to parents

III. Minimizing Problem Behaviors
  • that interfere in classroom activities

Commonly reported challenging behaviors in the
  • Interrupting and other impulsive verbal behaviors
  • Resistance to changes in routine
  • Insistence that certain rules be followed
  • Concrete style
  • Poor handwriting
  • Difficulty accepting mistakes
  • Little patience
  • Driven quality
  • Social vulnerability
  • Distractibility
  • Perseverations or obsessions

Consider the message the behavior is sending
  • Is confused, needs help but has difficulty
    communicating under pressure
  • Feels negative affect (e.g., anxiety, worry, sad,
    mad) and doesnt know how to manage it
    physiologically and behaviorally
  • Wants to escape
  • Craves predictability
  • Wants to interact, doesnt know how
  • Thinks he cant do something well, so doesnt try

Avoid Contingencies and Instead.Catch the
Student Being Good
  • Always be on the look out to praise or reinforce
    good attention, effort, participation, waiting,
    tolerance, acceptance of change, coping, etc.
  • Link rewards to effort and participation but
    provide intermittently and not with a formalized
    contract ahead of time

Set Clear Limits
  • Anticipate challenging situations
  • Share written rules/guidelines with student for
    specific situations
  • Be explicit, rule-governed, clear, consistent
  • Pick and choose battles

Use clear and specific language to shape behavior
  • Avoid phrases like behave yourself not
    specific enough
  • Tell the student exactly what is expected and for
    how long You need to be sitting quietly and
    reading your science book until 1115.
  • Emphasize words that indicate when now,
    later, etc. and gently redirect if student acts
    before it is time

Encourage Choice-making
  • Autonomy is often very important for these
    students use it to prevent problems and
    reinforce effort
  • Help student identify how choices are perceived
    by other people

Use Visual Reminders
  • Use post-it notes or index cards on the childs
    desk to remind him/her of appropriate behavior
    (e.g., raise your hand)
  • Instead of verbally reminding child, simply touch
    the card to send the message

Use the Buddy System
  • Encourage the child to watch what another student
    does and model that behavior
  • Rotate buddies
  • Whenever possible, use same-gender buddies

Minimize down time
  • Give the child 2-3 functional activities to
    engage in when he/she has completed work and is
    waiting for the next activity
  • Provide clear rules about behavior during down
    time or independent work.

Use a ticket out system
  • Provide a limited number of tickets out of the
    classroom per day
  • Provide written guidelines to the student for
    where to go, how long, etc.
  • Determine a safe place to go and/or supervision
  • Teach the student when to use the tickets
  • Reinforce appropriate use

Plan for alternative activities
  • For example, if cafeteria is too noisy and
    upsetting, create a plan for eating and going
  • It may not be useful for some students to
    participate in all classes, assemblies, field
    trips etc. make these decisions with parents

When problem behaviors occur
  • Label the misbehavior in a calm, neutral manner
  • Whenever possible, allow natural consequences to
  • Do not process/discuss problem behavior in the
  • Wait for a calm time to discuss what the student
    could have done differently

Encourage self-reflection
  • Help student to identify situations that are
    particularly challenging for them
  • Help student to create a list of options for
    responding to these situations in the future
  • Use self-reflection to strengthen self-esteem
  • Demonstrate differences between students
    perspective and others perspective

IV. Improving social competence
A. Naturalistic Teaching
  • Narrating situations (Tony Attwood calls this
    being an anthropologist)
  • Setting up play/social situations that you can
    subtly observe and teach through
  • Bring good models into your house/classroom and
    structure play activities to encourage active
  • Prime or prepare student with ASD
  • Choose shared activities that emphasize strengths
    and are cooperative, not competitive

Peer Mediated InterventionsImproving Social
Relationships Among Children with Autism in
Inclusive Settings
  • Audrey Blakeley-Smith, Ph.D.
  • JFK Partners
  • University of Colorado at Denver and Health
    Sciences Center

Research on Inclusion for Students with ASD
  • Changes in problem behavior (stereotypies,
    self-injury) (Lee Odom, 1996 McGee, Paradis
    Feldman, 1993)
  • Changes in academic performance (Saint-Laurent
    Lessard, 1991 Saint-Laurent, Fournier Lessard,

Social Inclusion What Does the Research Say?
  • Students in integrated settings spend more time
    engaged in interactions than students in
    segregated settings (Center Curry, 1993)

But What Does this Mean
  • Interactions between students with special needs
    and their peers, are often one-sided and didactic
  • 78 of student interactions were instructional
  • lt5 of student interactions were social
  • (Farrell, 1997 Hilton Liberty, 1992)

Social InclusionWhat Do the Peers Say?
  • Typical peers often report that they have
    insufficient knowledge and inadequate
    communication strategies (York Tundidor, 1995)
  • Most peers prefer to interact with each other
    rather than children with HFA (Chamberline,
    Kasari, Rotheram-Fuller, 2007)

Social InclusionWhat do Children with ASD say?
  • Children with HFA tend to view themselves as more
    socially involved than their peers report
    (Chamberlin, Kasari, Rotheram-Fuller, 2007)
  • Children with HFA report greater loneliness than
    their typical peers (Bauminger Kasari, 2000)

Peer Mediated Interventions
  • Choose Peers Who Are
  • A part of the childs social world
  • Interested
  • Attentive to adult instruction
  • Responsive to adult praise

Preparing Peers
  • Learn about their interests and motivations
  • Discuss goals of group
  • Teach how to prompt/help
  • Role play prompting/helping
  • Systematically fade reinforcement

Does sharing the autism diagnosis with peers help?
  • Negative attitudes frequently persist despite
    providing children with information about ASD
    (Swaim Morgan, 2001)
  • By the 5th grade, students are no longer as
    receptive to explanatory information regarding
    ASD (Cambell, 2006)

Guidelines for Peer Prompting
  • Teach peers to provide visual and gestural
    prompts as well as sentence starters, help
  • Encourage peers to help more in the beginning and
    less at the end of a task
  • Teach peers to wait for a response from target
  • Focus peers on prompts and praise, not criticism
    or correction
  • Emphasize modeling

Teach Peers to Respond Appropriately
  • Follow and redirect
  • Persistence
  • Patience
  • Change their expectancies regarding the nature of
    the interaction
  • Change their attributions for the childs behavior

Cognitive-Behavioral Approaches
  • Using narrative strategies (scripts, video
    examples, comic strips, social stories) to
    clarify basic social concepts
  • Relying on a childs cognitive strengths to
    compensate for lack of social insight

This section relies heavily on contributions
from Audrey Blakeley-Smith Audrey.blakeleysmith
Social Narratives
  • Purpose
  • To teach social rules and the reasons why
    situations are handled in certain ways
  • Provide alternatives and/or coping strategies
  • How to
  • Review Carol Grays website or see Gray, 1993
    Gray, 1994 Fullerton, Stratton, Coyne, Gray,

Differentiating situations
Behavior in library .is the same as in the bank, dentist office, etc.
Behavior with little sister ..not the same as behavior with friends
Behavior on the playground not the same as behavior in the car
Comic Strip Conversations
  • Purpose
  • Increase social understanding of difficult
  • Incorporates the use of color and simple drawings
    to improve the students understanding of
    language and social interactions (Gray, 1994
    Fullerton, Stratton, Coyne, Gray, 1996)

Conversation symbols representing
quiet words
LOUD words
Colors Representing Emotions
  • Green good ideas, happy, friendly
  • Red bad ideas, teasing, angry, unfriendly
  • Combined colors confusion
  • Setting symbols to indicate the setting for the
    social situation

Comic Strip Conversations
  • How to
  • Review With the student, draw the difficult
    social situationsupport the student in
    identifying thoughts and emotions
  • Practice Help the student identify more
    appropriate ways to respond in similar social
    situations in the future draw these pictures

Using comic strip conversations to understand
social situations
  • Who is challenging me?
  • Where are we?
  • What are the rules?
  • Who is on my side here?
  • What happened just before?
  • What happened just after?
  • What should I do next time?

Social Scripts
  • How to
  • Identify age-appropriate social interactions,
    language and behaviors
  • Develop a script
  • Practice the script with the student
  • Alter the language/behaviors to reduce rigidity
  • Support the student to initiate and complete the
    script with a peer(s)

Social Scripts
  • Scripted conversations and interactions
  • E.g., Scripts for entering/leaving
    classroom/activity, going to McDonalds etc.
  • Scripts for classroom jobs
  • E.g., paper distributor make eye contact or tap
    shoulder and make eye contact, Heres your paper

  • Purpose
  • View videos to
  • Highlight salient social cues
  • Highlight specific social communicative behaviors
  • Create videos to teach
  • Imitation, play, community expectations,
    replacements to challenging behaviors, language
    and conversation skills

How to View Videos/TV
  • Have the student observe and interpret nonverbal
    messages in the show
  • Have the student make predictions about behaviors
  • Video Detective (Smith Myles Southwick, 1999
    Attwood, 1998)

How to Create Videos
  • Identify target social behaviors situations
  • Videotape familiar peers in those situations
    engaging in appropriate social behavior
  • Make the social cues and target behavior the most
    salient aspects of the video
  • Have the child view the video and critique their
    own and others behaviors
  • From Quill, K. A. (2000). Do-Watch-Listen-Say

How to Use the Created Video
  • View the video regularly (daily)
  • Preview the video just prior to the relevant
  • Pair the video with other visual cues to use as
    instructional prompts in the actual situation
  • Fade video viewing as the skills are mastered in
    the actual setting

Modeling and Rehearsal
  • Purpose
  • To highlight the key behaviors that the child
    should attend to in developing a social sequence
  • How to
  • Peer or adult demonstrates the appropriate social
    skill for the child to imitate
  • do in vivo, during role play, or set up
    situations for practice

Acting Lessons
  • Purpose
  • Role-playing and acting may help the child to
    express emotions verbally and nonverbally
  • The child may learn to interpret others
    emotions, feelings, and voices
  • (Smith Myles Southwick, 1999 Attwood, 1998)

C. Direct Instruction
  • Adult-directed activities
  • Lesson-like
  • Involves lots of practice and repetition
  • Reinforce effort and attention and scaffold
    enough to ensure success
  • Goal is to master basics think of learning a
    foreign language!!

Individual Work
  • Include parents whenever possible
  • Incorporate homework
  • Use a notebook system
  • Clearly define goals and review progress
    regularly in sessions with child and parent

Individual Work (cont.)
  • Use childrens books, art, music, games,
    physical activities, worksheets, puzzles,
    videotape, roleplays, snack time
  • Remember if you use this approach alone -- you
    wont get much
  • carry-over of skills

  • Same focus of individual work, but with another
    child attending also
  • Choose a peer from the school or neighborhood
  • Parents still attend and homework is often
    focused on fostering interaction between the two

Small Social Skills Groups
  • 4-6 children
  • 1-2 adults
  • Target to Peer ratio of 21 or 11
  • Stable vs. variable peers

Adult Interaction
  • Model and narrate appropriate social behavior in
    a very obvious way
  • Use humor and lighthearted approach
  • Provide frequent praise and reinforcement for
    effort and attention

Choose a Focus for the Group
  • Cooperative Play
  • Problem-Solving
  • Emotional Understanding
  • Social Understanding
  • Pragmatic Language
  • Emotional Regulation
  • Basic Social Interaction
  • Leisure Skills

Determine Setting/Logistics
  • Where?
  • How Often?
  • How long?
  • Rules?
  • Materials?

Planning a Session
  • Emphasize routine
  • Provide visual structure
  • Apply the 70/30 Rule of Repetition
  • Incorporate special interests

Planning (cont).
  • Alternate tasks by difficulty, activity level
  • Teach using multiple modalities
  • Start each session with a snack
  • End each session with R
  • Maintain close contact with families

Teaching Activities
  • Use existing social skills curricula
  • (see reference list)
  • Use actual situations to fuel lessons within a
    predictable framework
  • Know the childs peer group and be
    developmentally informed

Dealing with Teasing and Bullies (Ozonoff, 2002)
  • Establish peer buddies and foster good peer
  • Teaching classes on tolerance, diversity,
    learning styles
  • Assertiveness training
  • Asking for help, finding safe places, walking
    away, using humor

Resources for Teasing/Bullying
  • Bully-proofing your child A parents guide by
    Garrity, Mitchell, Porter (2000).
  • Bully-proofing your school A comprehensive
    approach for elementary schools. Garrity et al.
  • For children Bullies are a pain in the brain by
    Trevor Romain

Talking to a Child About Having Autism
  • Often best to wait until they have questions
    often comes up at around age 10 or so
  • Many good books available to help to educate kids
    about their condition see
  • Be matter of fact and calm and positive
  • Discuss it as a way to describe a persons
    strengths and challenges, not as a way of
    capturing the whole person
  • Have the conversation several times

In Conclusion
  • Need to think developmentally when planning
    screening, assessment, or intervention
  • There are many good resources for intervention
    for kids of different ages and functioning levels

Thanks to
  • Families who participate in our research and
    clinical activities at JFK Partners of the
    University of Colorado at Denver and Health
  • The Nebraska Autism Spectrum Disorders Network
  • Laura Maddox, State ASD Coordinator

This work has been funded by
  • National Institute of Child Health and
    Development (U19 HD035468)
  • National Institute of Communication Disorders and
    Deafness (R21 DC005574-03)
  • Association of University Centers on
    Developmental Disabilities
  • University Centers of Excellence
  • Cure Autism Now
  • March of Dimes
  • Organization for Autism Research
  • Autism Speaks
  • Doug Flutie Foundation

Research Team at JFK Partners and the University
of Colorado at Denver and Health Sciences Center
  • Director
  • Susan Hepburn, Ph.D.
  • Mentors
  • Sally Rogers
  • Bruce Pennington
  • Corry Robinson
  • Linda Crnic
  • Collaborating scientists
  • Deborah Fidler, Ph.D.
  • Judy Reaven, Ph.D.
  • Audrey Blakeley-Smith, Ph.D.
  • Amy Philofsky, Ph.D.
  • Ann Reynolds, M.D.
  • Daniel McIntosh, Ph.D.
  • Eric Moody, Ph.D.
  • Don Rojas, Ph.D.
  • Hilary Coon, Ph.D.
  • Kathy Culhane-Shelburne, Ph.D.
With Appreciation to Many Students and Research
Assistants Over the Years
  • Katy Ridge
  • Galit Mankin, M.S.W.
  • Athena Hayes, M.S.
  • Angela John, M.S.
  • Benjamin Yerys, Ph.D.
  • Erin Flanigan
  • Helga Simons
  • Mark Guiberson, Ph.D.
  • Elizabeth Eno, M.S.
  • Susan Murray, CCC-SLP
  • Kym Gilchrist
  • Nancy Lee, Ph.D.
  • Terry Hall, CCC-SLP
  • Renee Charlifue-Smith, CCC-SLP
  • Alison Herndon, MPH
  • Kristina Kaparich, MPH
  • Marissa Sellinger, M.S.
  • Lila Kimel, M.S.
  • Shana Nichols, Ph.D.
  • Tracy Stackhouse, OTR
  • Megan Martins, Ph.D.
  • Mim Ari
  • Norbert Nguiya