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Early Intervention for Toddlers with Autism Spectrum Disorders
Is It a Special Case?
Hannah Schertz, Ph.D.
Autism Spectrum Disorders (ASD)
Social communication disorder with repetitive or stereotypical behavior and/or fixed interests
Wide-ranging in severity4-5 times more prevalent in boys than girlsPrevalence in 8-year-olds is nearly 1:100
http://www.cdc.gov/ncbddd/autism/data.html#prevalence
Increase due to broader diagnostic criteria, awareness, improved screening and diagnosis
(Odom, Schertz, Wong, in press)
ASD in ToddlersAll
Difficulty with preverbal social communication◦ Looking at others’ faces◦ Reciprocal back-and-forth interaction with a
partner◦ Sharing attention about mutual interests
Some Fixed or repetitive interests and behaviors
(may not appear until later)Challenging behaviors related to
communication difficulties and/or fixed interests
(Boyd, Odom, Humphreys, & Sam, 2010)
Causes
Genetic influenceConnected to vaccines?
Disproved in multiple studiesBrain differences: Effect or cause?
Early Identification
Why is it important?◦Improved outcomes with early
intervention ◦Early support and education for
parents
Early Identification
How can early educators help? ◦Know red flags◦Listen and respond to parents’
concerns◦Provide prompt access to screening
and diagnostic evaluation ◦Be vigilant
Red flags for toddlers
Not “showing” objects or following points
No ‘pretend play’ by 18 monthsAvoiding looks to others’ facesRepeating actions over and over Difficulty adjusting to new routines
http://firstsigns.org/ http://firstwords.fsu.edu/ http://www.ddhealthinfo.org/documents/ASDquickguide.pdf
Communicating with FamiliesResponding to family suspicion of
ASDTake seriously: Parents often raise
first concern; want prompt answersFacilitate screeningRefer for diagnostic evaluation if
screen shows high riskAvoid suggesting ASD before
diagnosis
Communicating with Families
If you have concerns before the family does:Offer screening to all familiesAvoid using “autism” terminology Avoid writing off reticence as “denial”Keep in touch for support and follow-up Proceed on parents’ terms –when
ready.Do not wait for diagnosis to address
social communication needs
Screening
Modified Checklist for Autism in Toddlers (MCHAT; Robins, Fein, Barton, & Green,
2001): Free parent questionnaire & instructions
http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D..html
Who can administer? ◦ Parent completed◦ Simple scoring procedures◦ Follow-up interview for greater
reliability
Evidence-based Intervention
Approaches reported for toddlers
with ASD
◦Traditional behavioral
◦Naturalistic behavioral
◦Developmental
Evidence-based Intervention
Consider each approach for:◦Intensity: Implications for each◦Effectiveness : The big picture, not
just narrow skills (Buysse & Wesley, 2006) ◦Outcomes: Socially grounded,
meaningful in everyday life, developmentally appropriate
◦Process : How it fits with principles of practice for toddlers and families’ values/priorities
Traditional BehavioralLovaas: Traditional Applied Behavioral
Analysis (ABA); Discrete Trial TrainingLearning theory: Modify what comes before
or after to elicit, change, eliminate behaviors
Adult directed (; prescribed learning tasks)Intensive (35-40 h/w)Prompting, reinforcement, fading, time-
delayResearch counters unqualified effectiveness
claimsIn widespread use
Naturalistic Behavioral
Similar to traditional behavioral view that children learn by modifying behaviors in response to environmental contingencies
Considers child interests & motives (more child centered); natural reinforcers
Gaining ground over traditional ABAExamples: Pivotal response treatment
(emphasizes behaviors important for broader learning); incidental teaching
DevelopmentalChild brings internal competency to learningAdults follow child’s lead to promote
spontaneity, initiative, & self-directed learning
Promotes internal motivation, natural consequences
Emphasizes social relationships, affect sharing
Examples: Developmental Social Pragmatic, Joint Attention Mediated Learning (JAML), Early Start Denver Model (hybrid)
Early Intervention: Core Principles
1. Family-centered and strengths-based
2. Natural and inclusive environments3. Developmentally sound4. Active and functional child
engagement5. Coordinated and systematic
Schertz, H. H. (in press)
Intervention for Toddlers with ASD
Observing practices for toddlers with ASD:How do current practices fit with
each principle?How can we reconcile differences
or make changes when there is not a fit?
Principle 1:
Family-centered & Strengths-basedFamily-centered
◦Incorporates family priorities◦Supports parent-child relationship
rather than replacing it with professional-child interaction
Strengths-based◦Views families as capable ◦Enables (rather than trains) families to
promote toddler social development
Principle 1:
Family-centered & Strengths-based
Which best promotes an active family role?
◦Child participates in prescribed, highly structured intervention
◦Train parents in specific behavioral strategies
◦Support families to use their knowledge of the child to embed learning throughout everyday activities
Principle 2:
Natural & Inclusive Environments
Part C requirementGroups mirror the general population in
proportion of children with disabilitiesBenefits
◦It is where most learning occurs◦Facilitates natural family role◦Embeds learning in natural everyday
activities with familiar people◦Naturally facilitates generalization of
learning
Principle 2:
Natural & Inclusive Environments
Which best promotes learning that is meaningful in the everyday world?
◦ Clinic-based or segregated settings◦Professionally implemented in natural
settings with expectation that learning will carry over
◦Natural settings with learning embedded into natural activities with familiar people
Principle 3:
Developmentally Sound Intervention
Follow natural developmental sequences◦Address preverbal social communication first◦Build on natural precursors
Motivate, prevent behavior challenges with:◦Developmentally appropriate activities◦Activities that match development &
interests◦Respect for child’s tolerance level
Principle 3:
Developmentally Sound Intervention
Which belief(s) about learning challenge the child just above current skill levels?◦Learning occurs by modifying behaviors◦Learning occurs by modifying behaviors
with consideration for child interests◦Learning builds on current competencies;
considers foundational competencies that can take child to a new level
Principle 4:
Active, Functional Child EngagementSocial communication is more than a collection of isolated skillsFollow child’s lead rather than
prescribing highly structured activities & materials
Encourage child initiative, not just responding
Avoid dependency on external rewardsPromoting foundational competencies
helps children learn on their own
Principle 4: Active, Functional Child Engagement
Which promote(s) meaningful engagement?◦Activities selected & directed by adults with
structured protocols; child engagement is maintained through reinforcers
◦Activities incorporate child interests, create opportunities for natural reinforcers
◦Activities follow child’s lead; goals promote meaningful social engagement in everyday interactions; passive responding is less valued
Principle 5:
Coordinated & SystematicTeam members provide systematic
background support rather than side-by-side services
Guidelines for developmental approaches: ◦ Intervene in the “zone of proximal development”◦ Embed learning within meaningful social contexts ◦ “Scaffold” learning ◦ Mediate learning (planfully) rather than “train”
Guidelines for behavioral approaches: ◦ Promote pivotal (foundational) learning◦ Use tested strategies; follow child interests◦ Avoid focus on narrow skills with limited
relevance to everyday life or to meaningful future goals
◦ Support generalization by working in natural environments
Principle 5:
Coordinated & Systematic
Which are coordinated & systematic?◦ Specialists organize services around areas of delay;
team defers decisions to specialists; may be intrusive, inefficient, and at cross purposes
◦ Team members (including parents) share expertise, encouraging others to consider their goals.
◦ Team members systematically support each other’s learning, fading support as expertise is gained
◦ Outcomes and intervention processes are planned and delivered systematically considering evidence of effectiveness and developmental research
Is toddler intervention in ASD a special case?
Yes
Focus on preverbal social
communication
No
◦Toddlers with ASD are children first
◦Principles of good early intervention
apply
Online ResourcesAssociation for Science in Autism Treatment http://
www.asatonline.org/ Autism Society of America
http://www.autism-society.org/site/PageServerAutism Speaks. http://www.autismspeaks.org/Centers for Disease Control: Autism Spectrum Disorders
(ASDs) http://www.cdc.gov/ncbddd/autism/index.htmlIndiana Resource Center for Autism (IRCA).
http://www.iidc.indiana.edu/irca/ National Early Childhood Technical Assistance Center
(NECTAC): Autism spectrum disorders. http://www.nectac.org/topics/autism/autism.asp
National Research Council (2001). Educating children with autism. http://www.nap.edu/openbook.php?isbn=0309072697
ReferencesBoyd, B. A., Odom, S. L., Humphrey, B. P., & Sam, A. M. (2010).
Infants and toddlers with autism spectrum disorder: Early identification and early intervention, Journal of Early Intervention, 32(2), 75-98.
Buysse, V., & Wesley, P. W. (Eds.; 2006). Evidence-based practice in the early childhood field. Washington, D.C.: Zero to Three.
Odom, S. L., Schertz, H. H., & Wong, C. (in press). Autism spectrum disorders in young children. In H. H. Schertz, C. Wong, & S. L. Odom (Eds.). Young Exceptional Children Monograph 12: Supporting Young Children with Autism and Their Families. Missoula, MT: Division for Early Childhood.
Robins, D. L., Fein, D., Barton, M.L., Green, J.A. (2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31, 131-144.
Schertz, H. H. (in press). Principles of intervention for young children: Implications for toddlers and preschoolers with autism spectrum disorders. In H. H. Schertz, C. Wong, & S. L. Odom (Eds.). Young Exceptional Children Monograph 12: Supporting Young Children with Autism and Their Families. Missoula, MT: Division for Early Childhood.