Exam 2 Flashcards
least credible level of evidence
Expert committee report
most credible level of evidence
**Gold standard
systematic meta-analysis of more than one randomized control trial.
Other levels of evidence
-more credible to less credible
- well-designed, randomized control trials
- well-designed control trials without randomization
- well-designed, quasi-experimental studies
- well-designed, non-experimental studies
what is the five step approach to EBP
- ask question
- use best evidence to answer question
- determine if results pertinent to patient
- determine if evidence applicable and feasible to patient
- measure performance following intervention
medical intervention for ASD
- What types are used?
- anti-psychotic medication
- Serotonin-reuptake inhibitors
- stimulants
Medical interventions
- anti-psychotic meds, why?
- decreases challenging behaviors: irritability, aggression, self-injury.
examples: risperidone (risperdal), aripiprazole (abilify), haloperidol (haldol)
Medical intervention
- serotonin reuptake inhibitors, why?
- decrease repetitive and problem behaviors
Examples: fluoxetine (prozac), citalopram (celexa)
Medical Interventions
- stimulants, why?
- decrease hyperactivity
Examples: methylphenidate (ritalin), amphetamine, dextroamphetamine
Types of complementary/alternative medicine
- Biologically based therapies
- mind-body interventions
- manipulation/body-based methods
- energy therapies
- alternative medical systems
Biologically based therapies for ASD
- modified diet (gluten free diet, casein free diet, sugar free diet)
- vitamins/minerals (vitamin B6, Magnesium, Zinc, Vitamin C)
- food supplements (fish oil, Omega-3)
Mind-body interventions
- prayer/shaman (“getting the evil out”)
- biofeedback (EEG, EMG)
- meditation/relaxation
- Guided imagery (hypnosis)
Manipulation/body-based methods for ASD
- massage/bodywork
- craniosacral therapy (head massage)
- special exercises (yoga, tai chi)
- auditory integration
- vagus nerve stimulation (implant in Vagus nerve)
Energy Therapies for ASD
- Healer/healing touch
- REIKI
alternative medical systems for ASD
- acupuncture/acupressure
- anthroposophic medicine
Most common individual therapies for ASD
- Modified diet (38%) -> no conclusive evidence of effectiveness, should be recommended only for children with Celiac disease or food allergies.
- Vitamins/minerals (vitamin B6) (30%) -> no conclusive evidence of effectiveness. long term supplementation has led to sensory peripheral neuropathy.
- Food Supplements (23%) -> no conclusive evidence of effectiveness.
What is the most common complementary/alternative medicine for ASD?
- Modified Diet
evidence for medical intervention
- anti-psychotic medication
- Risperidone -> 2 strong RCTs indicating decreased challenging behaviors (most common side effect: sleepiness).
- Aripiprazole -> 2 RCTs (both sponsored by the maker of the drug) indicated decreased challenging behaviors (most common side effect: sleepiness).
– Risk of tremor, rigidity, dyskinesia
evidence for medical intervention
- serotonin reuptake inhibitors
-1 RCT -> insufficient evidence
evidence for medical intervention
- stimulants
- 1 RCT -> insufficient evidence
- - Risk of increased challenging behaviors and loss of appetite
Major weaknesses in evidence for medical intervention for ASD
- studies supported by drug companies
- small sample sizes
- poor methodology
- inconsistent methodology
- no meta-analysis
- no comparison with behavioral interventions
- no comparison with behavioral + medication interventions
Enhanced Milieu teaching
- Skill specific
- targets children with ASD who are minimally verbal (but no nonverbal)
- imitate at least 80% of words on an imitation task.
- spontaneously use at least 10 words
- MLU less than 3
EMT Goal?
Evaluates what?
- Goal: semantic goals are created based on evaluations
- Evaluates:
- receptive, expressive, language sample, parent-report measure.
EMT treatment methods
- administrator: clinician or parent
- environment: clinic/school/home
- materials: toys and materials for play
- frequency: 24 sessions (clinician implemented 15-20 min.; parent implemented 45 minutes.)
- session aim: increase language complexity
EMT procedures
- environmental arrangment
- responsive interaction
- language modeling
- Milieu teaching prompts
Milieu teaching prompts
- most-to-least support
- imitation to initiation
- providing verbal choices
- opportunities to answer questions
- time delay
- modeling expanded language
EMT theoretical basis
- contemporary ABA - more naturalistic, transactional basis, typical communication opportunities.
- developmental language progession
- “behavioral”
EMT empirical basis
- therapist implemented
- parent implemented
- “established treatment”
- -> harder to generalize!
- -> single subject studies. do not have RCT studies for this.
Pivotal response treatment (PRT)
aka natural language paradigm.
- Comprehensive
- more “behavioral”
PRT
- Key vocabulary
- pivotal behaviors- once these skills are learned they lead to significant development in other domains.
- motivation
- responsivity to multiple cues
- self-initiations
- self-management
PRT goal creation
- evaluate overall functioning (developmental, adaptive behavior, and language skills)
- goals are based on the evaluation. can work on multiple domains simultaneously, goals within one domain are addressed sequentially.
PRT treatment methods
- administrator: clinician or parent - must be trained!
- environment: clinic/school/home - “individual typical environment”
- materials: toys with multiple parts
- frequency: all waking moments are teaching moments
- session aim: language; play; social interactions; self-help; academic
PRT procedure
- presentation of an opportunity to respond:
- get child’s attention
- present an opportunity
- incorporate multiple cues
- intersperse maintenance tasks
- share control
- Reinforcement given following a response:
- reinforce contingently and immediately
- reinforce attempts
- natural, direct reinforcers paired with social praise.
PRT theoretical basis
- pivotal areas of development
- family involvement
- natural environment
- “behavioral”
PRT empirical basis
- parents can successfully implement PRT
- lots of studies, primarily single-subject design, few RCT
- “established treatment”
Behavioral intervention strategies
- not necessarily “ABA”
- Key vocabulary:
- discrete trail instruction or discrete trail training
- differential reinforcement
- shaping
Behavioral intervention
- Goal creation
- evaluate preparedness to learn (able to sit? able to attend? able to respond? etc)
- evaluate communication/social skills (VB-MAPP, Assessment of Basic Language and Learning Skills-Revised)
- Goals: addressed in developmental progression, may be identified according to a curricular guide, maintenance goals interspersed.
Behavioral Intervention: Treatment Methods
- Administrator: supervising clinician (BCBA), direct care clinician, parents
- environment: home/school/clinic; often a dedicated space where teaching occurs “table time”
- material: data collection tools, reinforcers, teaching materials
- frequency: 40 hours a week?
- session aim: improve specified goals for the session.
behavioral intervention
- treatment methods
- Procedure:
- discrete trial introduction (instruction, response, consequence intertrial interval)
- verbal behavior (mands (request), tact (label), echoic (imitation), intraverbal (response), textual (reading), transcription (writing)).
What is missing??? - PRAGMATICS!! - Prompts: physical (physically moving them), gestural, verbal, visual, model, positional, fading.
Behavioral intervention
- teaching variants
- errorless learning
- trail and error
behavioral intervention
- shaping
- gradually modifying behavior by reinforcing more complete behaviors.
Behavioral intervention
- differential reinforcement
- access to reinforcers for correct responses but a lack of access to reinforcers for incorrect responses.
Theoretical basis for behavioral intervention
- behavior analysis
- operant conditioning (planned and unplanned consequences)
- antecedents
Empirical basis for behavioral intervention
- Lovass (1987) - social interaction and social communication piece was missing here!! (looked at cognitive outcomes)
- established treatment
Joint Attention Intervention
aka JASPER
- Skill specific intervention
- more developmental
- Key Vocabulary: joint attention routines, joint attention, Joint engagement.
JASPER
- goal creation
- evaluate level of joint attention
- M-CHAT 2, early social communication scale, parent-child interaction, non-structured play observation with adult.
- evaluate play skills
- Goals: 1st goal: emerging skills.
JASPER
- treatment methods
- administrator: clinician
- environment: clinic/school/home
- Materials: toys and materials for play
- frequency: 30 minutes a day; 3-5 days a week for as few as 24 sessions total.
- session aim: spontaneous display of targeted skill
JASPER
- procedures
- play-selected by following the lead and interests, developmentally appropriate level
- set up environment
- follow the lead
- scaffolding
- expanding
- imitating
- prompting
- person-engaged play
JASPER
- theoretical basis
- “developmental”
- typical development of JA
- JA deficit in ASD
JASPER
- empirical basis
- original study: 2006
-
Developmental, Individual-Difference, Relationship-Based Model
aka DIR
is not just “floortime”
- comprehensive treatment
- key vocab: Child profile and Functional emotional developmental levels (FEDLs)
DIR Child Profile
- D: Functional emotional developmental levels (FEDLs).
- I: Individual processing profile - Individual differences in sensory, motor, and language abilities
- R: Caregiver-child relationship
FEDLs
according to developmental progression
- shared attention and regulation
- Engagement and relating.
- Two-way intentional communication
- complex problem solving.
- creative representations and elaboration
- Representational differentiation and emotional thinking.
DIR Multidisciplinary evaluation
- children are described using the Diagnostic Manual for Infancy and Early Childhood according to their level of relating and communicating.
- as well as the other domains of development central to DIR.
DIR
Goals
- Facilitating development at or above the FEDLs
- within the context of the individual processing profile.
- guiding caregivers to help children to move to higher FEDLs
DIR
Language levels
- self-regulation and interest in the world (birth-3mo.)
- forming relationships and affective vocal synchrony (2-7mo.)
- Intentional two-way communication (8-12mo.)
- first words: sharing meaning in gestures and words (12-18mo.)
- Word combinations: sharing experiences symbolically (18-24mo.)
- Early discourse: reciprocal symbolic interactions with others (24-36mo.)
DIR
Treatment Methods
- Administrator: clinical team: including clinician(s) and praent-those certified in DIR.
- Environment: clinic/school/home
- material: those needed to reach the goals.
- frequency: 6-8 20-minute sessions a day.
- session aim: improvement of FEDLs
DIR
procedures
- Floortime
- Goals addressing each FEDLs
- opening and closing circles of communication (turn taking)
- semi-structured problem-solving
- sensory motor activities
- parent coaching
DIR
Floortime
- spontaneous, developmentally appropriate interactions during which the FEDLs are mobilized
Theoretical background of DIR
- developmental
- interdisciplinary - combines all domains of development
- emphasizes the developmental level
- empirical support for development in each domain
Empirical background of DIR
- Greenspan and Wieder (1997) - retrospective chart review
- strength of additional research?
- “Emerging treatment” - 2009
Early Social Interaction Project (ESI)
- Comprehensive treatment
- key vocab:
- language stage (preverbal; early one-word; late one-word; multi-
word) . - SCERTS curriculum.
- natural environments.
- family-guided routines
- language stage (preverbal; early one-word; late one-word; multi-
ESI
Goal Creation
- evaluate social communication (CSBS DP, Describe the child’s language stage).
- SCERTS Assessment Process
- SAP defined meaningful and motivating goals.
- SAP defined learning contexts and intervention strategies and supports.
- Activity planning
ESI Goal Creation
SCERTS assessment process (SAP)
- social communication emotional regulation transactional supports
- comprehensive curriculum
- assessment in each domain
- gather information from multiple sources
- profile of strengths and needs
ESI goal creation
SAP defined meaningful and motivating goals should be
individualized
ESI Goal creation
Activity planning
- daily schedule to embed SC and ER goals.
ESI Treatment Methods
- Administrator: parent with clinician support; clinician must be trained in SCERTS
- Environment: home
- materials: those available in the family’s home
- frequency: daily - goal of 25 hours/week
- session aim: improvement on SC and ER goals
ESI treatment procedures
- family-guided routines
- parent-implemented embedded intervention
- collaborative consultation
- Positive behavior supports
Theoretical background for ESI
- Developmental
- child-directed
- natural-environments
- family-centered services and supports
- core-deficits of toddlers with ASD
Empirical background for ESI
- original study: 2006
- New RCT study: coming out in 2014
- various supports for the different components
Hanen - More than Words and Talkability programs
- 8 parent-group meetings
- 3 individual visits
- Hanen certified clinician
- manualized and well marketed (they do this well)
- catchy acronyms
- developmental
Early Start Denver Model
- comprehensive model
- “blended model” - combining applied behavior analysis and developmental practices.
- delivered in the homes - relationship focused.
- ESDM certified clinicians
- manualized
- strong evidence!
what is DIR
developmental, individual-difference relationship-based model.
What are the three components of DIR?
- functional emotional developmental levels (FEDLs)
- Individual processing profile.
- caregiver-child relationship
What does FEDLs stand for?
Functional emotional developmental levels
What are the FEDLs
- shared attention - birth to 3 months
- engagement and relating - 2-6 months
- 2-way intentional communication - 4-9 months
- complex problem solving - 9-18 months
- creative representations and elaboration - 18-30 months
- representational differentiation and emotional thinking - 30-48 mo.
what are the elements of the individual processing profile?
Sensory Modulation
sensory processing
sensory-affective processing
motor planning and sequencing
types of neurodevelopmental disorders of relating and communicating
Type I: early symbolic with constrictions.
Type II: Purposeful problem-solving with constrictions
Type III: Intermittently engaged and purposeful
Type IV: Aimless and not purposeful
What is the primary assessment tool in the DIR process?
the Functional Emotional Assessment Scale
What are the 6 developmental language levels in the ICDL-DMIC?
- self-regulation and interest in the world (birth-3 mo.)
- Forming relationships and affective vocal synchrony (2-7 mo.)
- Intentional 2-way communication (8-12 mo.)
- 1st words: sharing meaning in gestures & words (12-18 mo.)
- word combinations: sharing experiences symbolically (18-24 mo.)
- Early discourse: reciprocal symbolic interactions with others (24-36 mo.)
What are the 8 developmental modalities?
- shared attention
- affective engagement
- reciprocity
- shared intentions
- shared forms and meanings
- emerging discourse
- sensory processing and audition
- motor planning
What are the 4 categories of treatments defined by the national standards project (national autism center)?
- established treatments
- emerging treatements
- unestablished treatments
- ineffective/harmful treatments
What category of treatment does DIR fall into?
emerging treatment
DIR goals address skills in which domains?
- social-emotional
- affective
- language
- sensory
- regulatory
- motor planning
- visual-spatial
- patterns of family interaction
What are the three types of activities used in DIR in the educational setting?
- Floortime
- semistructured problem-solving interactions
- motor, sensory, perceptual-motor, and visual-spatial activities
What are play routines?
a plan for how to play with a toy or use objects in a play activity. they have steps that are repeated and a predictable sequence of events.
what is the difference between joint engagement and joint attention?
Joint attention is used to refer to a specific set of gestures used for sharing.
Joint engagement refers to the overarching quality and connectedness of the interaction.
What are the states of joint engagement?
- unengaged
- object engaged: child is actively playing with an object in a functional way, no other person involved.
- person engaged: child is actively interacting with another person without toys or objects.
- supported joint engagement: child and adult are interacting with toy/object, but child may not be initiating or overtly aware of adult’s interaction. adult is “supporting” the interaction.
- coordinated joint engagement: child and adult both actively interacting. both are aware of other and both are initiating.
what are two main types of communicative intent?
- protoimperatives - requesting communicative actions
- protodeclaratives - joint attention communicative actions
Early communication skills satisfy which functions?
- making requests of others
- attracting attention to self
- directing another’s attention to some item/activity
- reacting to stimuli
- focusing own attention to item/activity or regulating own behavior
What are joint attention skills?
- coordinated joint look: child looks from adult to toy and back to share attention.
- showing: child has toy in hand and holds up toward adult to share attention
- give to share: child makes clear attempt to give toy to adult purely to share, not to communicate need for assistance with the toy.
- point: child points to object purely to direct adult’s attention to something of interest
What are the time requirements for joint attention intervention?
30 minute sessions, 3-5 days/week for as few as 24 sessions total.
Setting for Joint Attention Intervention?
lab, home, school setting…
What are the key components of JA intervention?
- evaluating and planning objectives based on a child’s joint attention skills.
- implementing strategies to increase spontaneous use of joint attention.
- collecting data and monitoring progress.
- terminating treatment.
What is the ultimate goal of JA intervention?
improve language skills in children by increasing the frequency of their spontaneous initiations of joint attention
what tools may be used to assess joint attention?
- language use inventory for young children (LUI)
- modified checklist for autism in toddlers (M-CHAT)
- Early Childhood Communication Scales (ESCS)
How can the clinician enable teaching of joint attention?
- setting up the environment.
- adjust physical orientation during play.
- set up the environment with developmentally appropriate toys.
- set up the environment to reduce distractions by removing extra
toys or items that may cause challenging behaviors.
What are the suggested strategies for JA intervention?
- Set up the environment
- follow the child’s lead
- scaffold skills
- expand language
- imitate
How do we set up the environment for JA intervention
- sit close to the child to make eye contact.
- arrange toys within reach.
- remove distractions
- use environment to facilitate child’s social and communicative attempts
How to follow the child’s lead during JA intervention
- wait before acting
- allow the child to explore the room
- show high interest in the child’s toy choice
How to scaffold skills during JA intervention
- identify the JA skill to scaffold.
- provide ample positive reinforcement of the child’s skills
- Use the prompt hierarchy to facilitate skill learning.
How to expand language during JA intervention
- talk about what the child is doing
- repeat what the child says
- expand on the child’s communication
- give corrective feedback.
How to imitate during JA intervention
- imitate the child’s actions on toys
- mirror back language
What is the prompt hierarchy?
- general verbal prompt (“what toy should we pick?”)
- specific verbal suggestion (“let’s play with the Dora doll”)
- verbal command (“get the Dora doll”)
- verbal command with gesture (Say “get the Dora doll” while pointing to Dora)
- Partial physical prompt (nudging the child’s arm toward Dora)
- full physical prompt (fully helping the child get Dora)
What are the four components of Enhanced Milieu Teaching (EMT)?
- environmental arrangement
- responsive interaction
- specific language modeling
- milieu teaching
What is the setting for EMT?
primarily in the home, during regular routines.
Parent-implemented
Can parents implement EMT strategies effectively and efficiently?
YES
What behaviors may be exhibited by individuals with ASD that would make EMT implementation difficult?
- restricted interests in activities and toys
- limited joint attention skills
- limited social engagement with adults during activities
- perseverative behavior
- verbal echolalia
- other challenging behaviors
What purpose does environmental arrangement play in EMT?
- building and extending play routine as context for modeling new vocabulary and other target forms.
- providing a foundation for using milieu teaching prompts to promote language production
When modeling language what do we need to pay particular attention to?
Children who are imitative and initiate language with a pronoun reversal, saying “you” when they mean “I”
In Milieu teaching, the sequence of prompts follows a ________ to ________ support strategy
most to least
What three characteristics of verbal behavior of children with ASD may interfere with effective use of prompts?
- indiscriminate imitation
- verbal echolalia
- resistance to verbal prompting
What can be used instead of prompts if a child is prone to prompt dependancy?
- environmental arrangement
- responsive interaction strategies
What does ESI stand for?
Early Social Interaction
ESI is an approach for _________ who are ________ _________ or have a diagnosis of ______ and their families.
TODDLERS who are AT RISK or have a diagnosis of ASD
NRC identified what as essential for ASD intervention?
- priority for instruction on functional, spontaneous communication; social instruction across settings; play skills with focus on peer interaction; new skill acquisition, maintenance, and generalization, in natural contexts; functional assessment and positive behavior support in address problem behaviors; and functional academic skills, when appropriate.
ESI is a _______ ________ approach
Comprehensive developmental
For ESI, evaluation begins with a _________ that is approximately _____ minutes, then continues for approximately ______ minutes.
- warmup
- 10 minutes
- 30-40 minutes
How many activities should the measure of social communication consist of (for ESI)
6
Define preverbal
ESI
fewer than 2 words
define early one-word stage
ESI
2-5 different words
Define late one-word stage
ESI
6-9 different words
define multiword stage
ESI
10 or more different words and 2 or more different word combinations
What does SCERTS stand for?
SC: social communication
ER: Emotional Regulation
TS: Transitional supports
The initial phase of a SCERTS program involves completion of the _______ _______ ________
SCERTS Assessment Process (SAP)
Purposes of the process of SCERTS are…
- to establish a profile of developmental strengths and needs
- to determine meaningful and motivating goals
- to select learning contexts and appropriate intervention strategies and supports
The second step in developing a SCERTS program involves what?
SCERTS Activity Planning
Findings essential to the implementation of ESI include…
- the importance of establishing what the learner (parent) knows and believes when entering a learning environment.
- ## the importance of having a strong understanding of the content.
ESI is built upon a ___________ ___________ approach and relationship with ____________ that facilitates their capacity to provide the child’s intervention.
- Consultative Coaching
2. Caregiver
What are the 2 core social communication impairments?
- impairment in joint attention
- impairment in symbol use
Do people have to have training to implement ESI?
Yes. Clinician must be trained in SCERTS
What are the key components of ESI?
- family guided routines
- individualized child and family curriculum
- parent-implemented embedded intervention
- collaborative consultation
- positive behavior supports
- team-based community coordination.
What are the 4 aspects of Pivotal Response Treatment (PRT) that provide a theoretical basis for its use?
- family involvement in design and delivery of intervention.
- treatment in natural environments
- treatment of key pivotal target behaviors
- implementation in home and school environments
What are the key pivotal behaviors?
- motivation
- responsivity to multiple cues
- self-initiation
- self-management
What is Overselectivity?
PRT
- individuals with ASD tend to do this.
- attend to only one cue (or part) of the stimulus, even though it may be an irrelevant cue.
What is Weak Central Coherence?
- a cognitive style in which the processing of parts takes precedence over the processing of wholes
Social stories target a range of functional outcomes _____________.
indirectly
About how long have social stories been around?
~ 20 years
Steps to developing and using a social story
- determine a topic
- gather individualized information
- develop the social story
- consider additional supports
- review and share the social story
- introduce the social story
- provide comprehension checks and revision
- generalization training, maintenance, and fading
Sentence types used in social stories
- descriptive sentences
- perspective sentences
- sentences that coach the audience
- sentences that coach the team
- self-coaching sentences
- affirmative sentences
- partial sentences
What are descriptive sentences
factual, objective, assumption-and-debate free statements that describe context and/or the relevant but often unspoken aspects of a situation, person, activity, skill or concept.
what are perspective sentences
statements that accurately refer to or describe a person’s internal state, or their knowledge, thoughts, feelings, beliefs, opinions, motivation, or physical condition, or health.
What are sentences that coach the audience?
statements that gently guide the behavior or the audience by describing a suggested response or a choice of responses.
what are sentences that coach the team?
statements that guide the behavior of the audience or members of his or her team. They describe a suggested response, a choice of responses, or self-coaching strategies.
what are self-coaching sentences?
statements written by the audience to identify a personal strategy to recall and apply its content in practice.
what are affirmative sentences?
statements that enhance the meaning of surrounding statements and often express a commonly shared value or opinion within a given culture.
what are partial sentences?
fill-in-the blank statements that check for comprehension, encourage the audience to make guesses regarding the next step in a situation, the response of another individual, or his or her own response.
video modeling seems to be effective for what age ranges?
all age ranges, with the possible exception of very young children from birth to 2 1/2 years of age.
what are the three main types of video modeling?
- adult/peer modeling
- point-of-view modeling
- self-modeling
What are the two forms of self-modeling
video modeling
- feedforward: person is shown video of self performing a new, yet developmentally appropriate behavior.
- positive self-review: watching videos of self to build fluency or proficiency in a skill already learned.
advantages and disadvantages to peer/adult modeling
advantages: easily staged and strong maintenance.
disadvantages: models may not generate high interest and mixed results for generalization.
advantages and disadvantages to self-modeling
video modeling
Advantages: good for situations in which lack of confidence is an issue, may generate higher interest than other forms, and strong generalization results.
Disadvantages: may be difficult to stage and more complex editing.
advantages and disadvantages to point-of-view modeling
video modeling
Advantages: easily staged, real-life depictions, and limited editing needed.
Disadvantages: limited range of behaviors and few studies as yet.
advantages and disadvantages to animation modeling
video modeling
Advantages: popular format for children and usually professionally produced.
Disadvantages: models may lack relevance and range and specificity of behaviors is limited.