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-