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Issues, Trends, and Scientifically-Based Practices for Children and Youth with Asperger SyndromeRichard L. Simpson, Ed.D., University of Kansas

Issues, Trends and Scientifically-Based

Practices for Learners with Asperger Disorder

Richard L. Simpson

University of Kansas

Progress and Challenges in the Behavioral Treatment of

Autism Conference

February 4, 2007

Boston, MA

Triad of Characteristics Among Individuals with

Autism Spectrum Disorders

Social Interaction Deficits

Speech/ Behavior

Language Deficits Anomalies

DSM-1V Diagnostic Criteria:

Asperger DisorderA. Qualitative impairment in social interaction:

� Significant impairment in use of nonverbal behavior, such as social interaction gestures, facial expression, eye-eye-contact, and body postures

� Inability to form and maintain developmentally appropriate relationships with peers

� Failure to spontaneously seek out others for interactions, such as by sharing interests, achievements, and so forth

� Difficulty with social or emotional reciprocity

B. Repetitive and restricted stereotyped patterns of behavior, activities, and interests:

� Significant preoccupation with one or more stereotyped and restricted interests

� Significant manifestation of nonfunctional routines or inflexible adherence to rituals

� Repetitive and stereotyped motor movements

� Significant and persistent preoccupation with parts of objects

C. Clinically significant social, occupational, or other functioning impairment

D. Absence of a clinically significant general language delay

E. Absence of a clinically significant delay in cognitive development of age-appropriate adaptive behavior (other than social interaction) and self-help skills

Co-Morbidity and Asperger Disorder

Mental Retardation

Communication Impairments

ADHD

Obsessive Compulsive Disorders

Mood disorders and Depression

Anxiety disorders

Explosive disorders

Salient Elements of Asperger

Disorder

• Social

• Communication

• Behavioral/Emotional

• Intellectual/Cognitive

• Academic

• Sensory

• Motor

Social and Behavioral

Characteristics of Asperger Disorder

Social

� Social withdrawal

�Unskilled initiations and responses

� Socially stiff, awkward, emotionally blunted, self-

centered, unable to understand social cues,

inflexible, lacking in empathy and understanding

�Emotionally vulnerable and easily stressed

�Easy targets for teasing and bullying

Communication and Language

Characteristics of Asperger Disorder

Speech/Language� Good speaking fluency

� Poor pragmatics

� Poor non-verbal skills

Cognitive/Academic� Generally average intellectual abilities

� Obsessive, narrowly defined interests

� Concrete/literal thinking style

� Rigidity and inflexible demeanor

� Poor problem solving skills

� Poor organization

� Difficulty in discerning relevant stimuli

Sensory and Physical/Motor

Characteristics of Asperger Disorder

Sensory

�Hypo-and hyper-sensitivity to stimuli

�Poor auditory processing, including sound

sensitivity

Physical/Motor

�Fine and gross motor challenges

Asperger’s Syndrome Characteristics

Affecting School Performance

� Distraction/Inattention

� Tunnel Vision

� Rote Memory

� Visual vs. Auditory Processing

� Problem Solving Difficulties

� Motor Skills

� Motivation

� Difficulty comprehending abstract concepts

� Difficulty distinguishing relevant and irrelevant information

The Need for Evidence-Based

Practices

• Long legacy of ineffective, overvalued and

invalidated methods

• Ethical and moral imperatives

• Federal mandates: NCLB and IDEA/IDEIA

• Limited opportunities to make a difference

Scientific Method and Ways of

Knowing

• Decision making strategies, including policy formation and judgments of intervention and treatment effectiveness:

�Personal experience and common sense

�Expert testimony

�Political and administrative influence

�Science

�Confirming and disconfirming hypotheses based on data

Asperger Disorder and “Truthiness”

• Merriam-Webster: “Truthiness” is 2006 word of the year

� “truth that comes from the gut, not books”

• American Dialect Society: “Truthiness” is 2005 word of the year

� "the quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true"

• Truthiness Impact on ASD:� Permitting uncritical acceptance of unproven methods for learners with

ASD has not yielded positive outcomes

� Scientific verification and an uncompromising demand for data-supported decisions are clearly in order

� Naive and credulous acceptances of ineffective methods and strategies and reliance on methods that lack proven efficacy have generally had a detrimental effect on students with ASD

Intervention Choice Guidelines

• Use of effective methods

• Appropriate intensity

• Meaningful outcomes

• Individualized programs

• Documentation of student progress

• Key question consideration� What are the anticipated outcomes of the option?

� What are the potential risks?

� How will the method be evaluated?

� What proof exists to support the efficacy of the method?

� What options would be excluded if a particular method was adopted?

ASD Interventions and

Treatment Options• Interpersonal Relationship

• Skill-Based

• Cognitive

• Physiological/Biological/Neurological

• Other Interventions and Treatments

• Sources:

• National Research Council. (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. Washington, DC: National Academy Press.

• Heflin, J., & Simpson, R.L (1998). Interventions for children and youth with autism: Prudent choices in a world of exaggerated claims and empty promises. Part 11: Legal/policy analysis and recommendations for selecting Interventions and treatments. Focus on Autism and Other Developmental Disabilities,13(4), 194-211.

• Heflin, J., & Simpson, R.L (1998). Interventions for children and youth with autism: Prudent choices in a world of exaggerated claims and empty promises. Part 1: Intervention and treatment option review. Focus on Autism and Other Developmental Disabilities, 13(4), 212-220.

• Simpson, R., de Boer-Ott, S., Griswold, D., Myles, B., Byrd, S., Ganz, J.,et al. (2005). Autism spectrum disorders: Interventions and treatments for children and youth. Thousand Oaks, CA: Corwin Press.

• Simpson, R.L. (2005). Evidence-based practices and students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 20(3), 140-149.

Interpersonal Relationship

Interventions & Treatments:

IntroductionMethods are based on the idea that individuals with ASD have a disability

related to a problem of emotion or emotional bonding� ASD is an emotional reaction to environmental factors

� Treatments for ASD associated with interpersonal relationship facilitation

� Seek to facilitate affect, attachment, boding, and a sense of relatedness

Treatments formsHolding Therapy

Gentle Teaching

Option Method (Son-Rise Program)

Developmental, Individual-Difference Relationship-Based Model (Floor Time)

Pet/Animal Therapy

Skill-Based and Environmental

Support Strategies

• Most commonly used and valid methods

• Designed to teach, maintain, or support

socially and functionally valid skills

• Relatedness and bonding are not direct skill

targets

Skill-Based Interventions &

Treatments

• Scientifically-Based Practices

� Applied Behavior Analysis

• Promising Practices

� Environmental Supports

Underlying ABA Assumptions and

Asperger Disorder Programming

• Learning is Based on Understanding and Manipulating Observable Behavior and Stimuli

• Diagnostic Labels May Be Independent of Interventions

• Interventions Must Be Empirically Judged

• Behavior is Controlled by Antecedent and Consequent Events

Physical Organization and

Environmental Supports

�Environmental modifications/supports

�Routines and structure

�Video modeling

�“Home-base” programs

�“Safe harbor” programs

�Competent buddy pairing

�Protection from teasing/bullying

Visual Supports and Schedules

• Assists students organize and predict daily events

• Assists students in knowing what will happen next

• Assists students transition from one activity to the next

• Visual support forms

�Pictures and/or icons of scheduled activities

�Strips of poster board on students desk that sequentially show pictures of scheduled activities

�Schedule student carries from class to class

Additional Visual Supports

That Support Behavior

� Task Organizers

� Turn Taking Cards

� Waiting Symbols

� Choice Making

� Rules and Alternate Behaviors

� Consequence Maps

� Calming Supports

� Transition Supports

� Introducing Change

� First, Then Cards

� Video modeling

Visual Schedule Intervention For Activity Transitions

(Jeff: Age 7)

Visual Schedule Intervention For Activity Transitions

(Josh: Age 5)

Cognitive Interventions

and Treatments

• Promising Practices

�Cognitive Behavior Modification

�Social Stories

�Video modeling

• Limited Support

�Power Cards

�Cartooning

Cognitive-Based Intervention

Methods • Involves using self-management strategies that teach students to

actively monitor and control their own behaviors

• Relies on self-monitoring (self-assessment, self-recording), self-evaluation (decision-making, goal-setting), and self reinforcement for goal attainment.

• Involves learners: � Differentiating the occurrence of a target response

� Reliably self-recording the target response in accordance with some specified standard

� Evaluating their behavior relative to the standard

� Delivering contingently self-selected rewards and reinforcement

� Frequently also involves students covertly or overtly verbalizing cues, questions and other information to themselves that they need to make correct responses

Basic Cognitive

Management Protocol

1. Operationally define the target behavior

2. Conduct discrimination training with student

3. Implement self-management: Self-monitoring,

self-recording and self-rewarding procedures

4. Implement and shape self-management (overt

speech, covert speech)

5. Support maintenance and generalization

Meta-analysis of the efficacy of self-

management

Synthesis of single-subject research using self-

management of students with autism as an intervention

across intervention and participants characteristics using

the percentage non-overlapping data (PND) metric

suggests that self-management interventions are an

effective treatment for increasing the frequency of

appropriate behavior of students with ASD.

Lee, S., Simpson, R. & Shogren, K. (in press). Effects and implications of self-management for

students with autism: A meta-analysis. Focus on Autism and Other Developmental Disabilities

Meta-analysis of the efficacy of self-management

Criteria:

� Used single subject research design was employed

� Recipient of the intervention had autism

� Self-management and its related components (i.e., self-monitoring, self-reinforcement, self-evaluation, and so forth) were primarily used to increase appropriate behavior (studies that also included behavioral targets for deceleration were included)

� Effect of the intervention on the identified appropriate behavior was empirically measured and graphically illustrated with clearly identifiable baseline and intervention phases

� Article was published in a peer-reviewed journal

Results:

� Overall mean PND score: 81.9 % (SD = 30.5), with a range from 0 to 100%.

� Interventions that were implemented with co-participants (e.g., peer-monitoring and adult monitoring) along with student self-monitoring resulted in higher PND scores (M = 91.5%)

� PND values were almost identical for young children and school-age students (M = 78.3% vs. M = 78.5%)

Social Stories*

Social Story Components:

• Descriptive sentences

• Perspective sentences that describe the feelings and reactions of others

• Directive sentences are statements about appropriate behavioral responses

• Affirmative sentences (a shared value within a given culture)

*http://www.thegraycenter.org/Social_Stories.htm

Social Story Talking with Adults

Social Story: Waiting

Social Story Results

Power Cards

• The Power Card strategy connects an appropriate

or desired behavior or social skill to an

individual’s area of special interest.

• Power Cards involve scenarios wherein a child’s

special interest, a hero, or a model connected to a

special interest models a solution to a problem

similar to the one experienced by the child.

The Power Puff Girls Play a Game

The Power Puff Girls like to play games. Sometimes they win the game. When

they win games the Power Puff Girls feel happy. They might smile; give each

other a “high five”, or say, “Yah”. Sometimes they lose the game. When they lose

games the Power Puff Girls might not feel happy. They might take a deep breath;

say “good job” to their friend; or say “maybe next time”.

The Power Puff Girls want everyone to have fun playing games. They want you to

remember these three things when playing games the Power Puff way:

1. Games should be fun for everyone.

2. If you win a game you can: Smile; give a “high five”, or say, “Yah”.

3. If you lose a game you can: take a deep breath; say “good job” to your friend; or

say “maybe next time”.

Play games the Power Puff way and your friends will have fun playing with you.

Physiological/Biological/Neurological

Treatments and Interventions

• Effective Practices

– Pharmacology

• Requires Additional Investigation

– Sensory Integration

• Limited Support

– Scotopic Sensitivity Syndrome: Irlen Lenses

– Auditory Integration Training

– Megavitamin Therapy and dietary supplements

Sensory Integration

• Ability to internally organize sensory input, including visual, auditory, tactile, olfactory, gustatory and vestibular

• Common characteristics of SI dysfunction

– Over/under reaction to stimuli

– Unusually high or low level of activity

– Coordination problems

– Behavior problems

Management and Social Skill

Considerations

• Behavior management and positive

behavioral supports

• Social skill/social interaction interventions

Suggested Management Considerations

for Students with Asperger Disorder

� Attempt to interpret behavior; “face value” behavior interpretations appears to be a problem� FBA analyses and communication intent assessment is essential

� Students with AS appear to have difficulty monitoring their own feelings; and may display limited overt emotional agitation prior to aggression or other strong reactions� Few cues or precursor’s to strong responses are common

� Students with AS often have limited strategies for meeting their needs; thus strategy instruction is essential� Limited capacity for independent problem solving, particularly during stressful

situations

� Antecedent manipulation and environmental structuring/support appear to be foundational elements of effective programs� Clearly stated behavioral expectations and rules, routines, schedules, etc

� Cognitive-based management methods frequently appear to be more effective than consequence-based “top-down” strategies� CBM and related methods appear to be particularly utilitarian

Positive Behavioral Supports

• Positive Behavioral Support Considerations

�Ecological considerations are a primary means of

understanding problem behavior

�Systems-level and environmental modification

strategies are primary means of changing problem

behaviors

�Understanding problem behaviors are more important

than merely extinguishing them

�Positive behavioral interventions are proactive rather

than merely reactive

Understanding Behavior

Positive Behavior Supports

Crisis

Management

ConsequencesSocial

Interaction

Environmental Modifications

Antecedent Modifications

Academic/cognitive

Supports

Salient Social Skill Contextual

Considerations

� Peer familiarity

� Peer gender

� Number of peers

� Intensity of social demands

� Activity preference

� Material preference

� Activity type

Commonly Used Social Interaction

Instruction and Interpretation Methods

Adult-Mediated Social Interaction Strategies

� Direct skill instruction

� Antecedent prompting

Peer-Mediated Social Interaction Strategies

Social Skill Instruction and Interpretation Strategies

� Video modeling and prompting

� Cognitive strategies and scripts

� Social Stories

� Power cards

� Cartooning

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., rev.). Washington, DC: Author.

Asperger, H. (1944). Die “Autistischen Psychopathen” im Kindesalter. [Autism psychopathy in children]. Archiv für Psychiatrie und Nervenkrankheiten, 117, 76–136.

Earles-Vollrath, T., Cook, K., & Ganz, J. (2006). How to develop and implement visual supports. In R. L. Simpson (series editor), PRO-ED series on autism spectrum disorders (pp. 1-60). Austin, TX: PRO-ED.

Gray, C. (1995). Social stories unlimited: Social stories and comic strip conversations. Jenison, MI: Jenison Public Schools.

Gray, C., & Garand, J. (1993). Social stories: Improving responses of students with autism with accurate social information. Focus on Autistic Behavior, 8(1), 1-10.

Hagiwara, T., & Myles, B. (1999). A multimedia social story intervention: Teaching skills to children with autism. Focus on Autism and Other Developmental Disabilities, 14(2), 82-95.

References

Lee, S., Simpson, R., & Shogren, K. (2006, in press). Effects and implications of self-management for students with autism: A meta-analysis. Focus on Autism and Other Developmental Disabilities, 21(4).

MacDuff, G. S., Krantz, P. J., & McClannahan, L. E. (1993). Teaching children with autism to use photographic activity schedules: Maintenance and generalization of complex response chains. Journal of Applied Behavior Analysis, 26(1), 89-97.

Mitchem, K. J., Young, R., West, R. P., & Benyo, J. (2001). CWPASM: A classwide peer-assisted self-management program for general education classrooms. Education and Treatment of Children, 24(2), 111-140.

Myles, B. S., & Simpson, R. L. (2003). Asperger’s syndrome: A guide for educators and parents. Austin, TX: PRO-ED.

Norris, C., & Dattilo, J. (1999). Evaluating effects of a social story intervention on a young girl with autism. Focus on Autism and Other Developmental Disabilities, 14(3), 180-186.