Autism & behavior therapy


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Autism & behavior therapy

  1. 1. Behavior Therapy for Teenagers and Young Adults with Autistic Spectrum Disorders Daniel C. Marston, PhD, ABPP Private Practice in Behavioral Psychology North Huntingdon, PA
  2. 2. Credentials • Board Certified in Cognitive & Behavioral Psychology, American Board of Professional Psychology • Fellow, American Academy of Cognitive & Behavioral Psychology • Fellow, Pennsylvania Psychological Association • Member, American Psychological Association Division 6 (Behavioral Neuroscience) • Member, American Association of Intellectual & Developmental Disabilities (AAIDD) • Over 15 years of practice specializing in providing behavioral health services to individuals with neurological disorders
  3. 3. Autistic Spectrum Disorders – General category of disorders that includes Autism, Asperger’s Disorder and Pervasive Developmental Disorder – Main symptoms of disorders include deficits in socialization, communication problems, repetitive behaviors and significant restrictions in terms of interests – Asperger’s Disorder does not include significant communication problems – Pervasive Developmental Disorder is seen as an autistic spectrum disorder that includes some but not all of the symptoms of autism – All of these disorders are considered to primarily be neurological disorders
  4. 4. Autistic Disorder—DSM-IV • (I) A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each from (B) and (C) • (A) qualitative impairment in social interaction, as manifested by at least two of the following: • 1. marked impairments in the use of multiple nonverbal behaviors • 2. failure to develop peer relationships appropriate to developmental level 3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, • 4. lack of social or emotional reciprocity • (B) qualitative impairments in communication as manifested by at least one of the following: • 1. delay in, or total lack of, the development of spoken language • 2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others 3. stereotyped and repetitive use of language or idiosyncratic language 4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level • (C) restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least two of the following: • 1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 2. apparently inflexible adherence to specific, nonfunctional routines or rituals 3. stereotyped and repetitive motor mannerisms 4. persistent preoccupation with parts of objects • (II) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: • (A) social interaction (B) language as used in social communication (C) symbolic or imaginative play • (III) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder
  5. 5. Asperger’s Disorder—DSM-IV • (I) Qualitative impairment in social interaction, as manifested by at least two of the following: • (A) marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction (B) failure to develop peer relationships appropriate to developmental level (C) a lack of spontaneous seeking to share enjoyment, interest or achievements with other people(D) lack of social or emotional reciprocity • (II) Restricted repetitive & stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following: • (A) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (B) apparently inflexible adherence to specific, nonfunctional routines or rituals (C) stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements) (D) persistent preoccupation with parts of objects • (III) The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning. (IV) There is no clinically significant general delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years) (V) There is no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood. (VI) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia
  6. 6. Pervasive Developmental Disorder NOS – DSM-IV • “This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities are present, but the criteria are not met for a specific pervasive developmental disorder, schizophrenia, schizotypal personality disorder, or avoidant personality disorder. For example, this category includes "atypical autism" --presentations that do not meet the criteria for autistic disorder because of late age of onset, atypical symptomatology, or subthreshold symptomatology, or all of these.”
  7. 7. What is EBPP? • Stands for Empirically Based Practice in Psychology • It is expected with professional community that treatment decisions will be based on principles of EBPP • Behavior therapy emphasizes empirical support for treatment interventions • Deciding what is EBPP for behavior therapy with teenagers and young adults diagnosed with autistic spectrum disorders will be primary focus of this presentation
  8. 8. Core Principles of EBPP (APA, 2006; Kazdin, 2008) • Evidence-based practice should have a ‘‘cogent rationale for clinical strategies’’ • Research findings and clinical expertise are both important for establishing an evidence base • Research base should include randomized controlled trials, but can and should take other forms as well • Clinical expertise can be reflected in experience and professional reputation
  9. 9. Core Principles of EBPP (continued) • Interventions should be individualized according to clients’ unique characteristics. • Intervention research should include real- life outcome measures • Truly effective treatments are those that are generalizable to complex real-life conditions and multiple cultures and settings.
  10. 10. NEUROLOGICAL ASPECTS OF AUTISM • Evidence from number of disciplines support that Asperger’s Syndrome & autism are variations of the same neurological disease (Coleman & Betancer, 2005). • Disciplines that address this issue and supported that conclusion include genetics & neurology.
  11. 11. In her book on the neurology of autism, Coleman (2005) offered a summary of the clinical symptoms of autism based on a review of the neurological research:
  12. 12. Coleman (2005) • Children with autistic syndromes have impaired social interactions • Children with autistic syndromes lack empathy (defined as lack of ability to integrate the cognitive and affective facets of another person’s life) • Children with autistic syndromes have a disabling need for sameness • Children with autistic syndromes exhibit repetitive & stereotypal patterns of behaviors
  13. 13. Coleman (2005)----continued • Children with autistic syndromes who do speak begin to talk at unusually late ages • Children with autistic syndromes who speak often have qualitative impairments in communication • It is not clear exactly what the specific neurological mechanisms are for these symptoms
  14. 14. What neurologists are able to say about the causes of autistic syndromes • Autism likely due to problems with neurological development at a very young age • General understanding from neurological research is that likely culprit is impaired connections of neural pathways
  15. 15. • Cause is likely either abnormally varied neural circuit or abnormality of neural components of one or more neural pathways • These problems lead to dysfunctional information processing of behaviors & cognition starting at a young age
  16. 16. Prefrontal cortex has been extensively implicated in autism to explain deficits in executive functioning, cognition, language, sociability & emotion • Rinaldi, Peroddin & Markram (2008) • Price (2006)
  17. 17. Pregenual Anterior Cingulate Cortex • DiMartino, Shehzad, Kelly, Krain et al (2009)—provided summary of research of role this area may play in autism • Plays a major role in person’s capacity to reason about thoughts & beliefs of others • Otherwise known as “theory of mind” • Hypofunction of this area in autism revealed in meta-analysis by DiMartino, Ross, Uddin, Sklar et al (2009)
  18. 18. Pregenual Anterior Cingulate Cortex has also been found to play roles in other disorders that include: • Depressive Disorders • Anxiety Disorders • ADHD • Schizophrenia This could help account for the large percentage of individuals with autism who have comorbid diagnoses
  19. 19. Chronic Stress & Prefrontal Cortex • Chronic stress can significantly impact on development of prefrontal cortex (Wilber et al, 2011) • Chronic stress does not necessarily effect whether autism develops but would significantly impact on how it develops • Could likely impact on the severity of symptoms associated with autistic spectrum disorders • One example would be chronic stress associated with poverty (Evans & Schamberg, 2009) • Impact of poverty on development of autism can likely be seen primarily in the effect on the prefrontal cortex region of the brain
  20. 20. Behavior Therapy & Neurological Factors of Autism • Behavior therapy can help address symptoms associated with neurological aspects of autism • Behavior therapy can help with development of skills that are lacking due to neurological aspects of autism • Behavior therapy can less impact of person’s environment on the neurological aspects of autism • Behavior therapy can help less impact of chronic stress on neurological development
  21. 21. Additional Information about Neurology & Autism • Nancy Minshrew, Professor of Psychiatry & Director of Center for Excellence in Research • “Essential Pittsburgh” Radio Show on 06/08/12 • Neurological Research shows underactivity in more advanced, frontal parts of brain & hyperactivity in more basic, posterior parts of brain • Means individuals with autism do not see comprehensive view of what is happening but tend to get focused on parts • Also found that part of brain that gets person to focus on themselves as part of situations is less activated in autism
  22. 22. • Means that person with autism needs to be in a situation in order to learn from it • Would help explain why generalization is such a problem in autism • Also underscores importance of covering skills in session to help individuals with autism learn what to do
  23. 23. Case Example • 14 year old female with Asperger’s • Significant problems with social skills • Particular concern because she will be starting high school soon • Used session for teaching and role playing of social skills • One issue that needed to be addressed was issue of generalization
  24. 24. Case Example (continued) • Learning skills for one situation would not make her comfortable in other situation • Even if those situations were similar • Needed to address social skills in classroom and then also social skills at lockers • Addressing multiple settings can help individual start to generalize
  26. 26. Klin (2007) outlined two of the main psychological theories of autism • Theory of Mind: emphasizes a disruption in capacity to impart mental states to others (e.g. beliefs, desires, intentions & feelings) or to have “theory of mind” • Weak Central Coherence: emphasizes that what is lacking in autism is the universal human drive to integrate information into coherent “wholes” or to link pieces of stimuli or meaning into contextual entities
  27. 27. Weak Central Coherence (WCC) Theory • Much of the research for this theory came from series of studies conducted at Yale University • WCC leads autistic individuals to be insensitive to the social context and leads them to respond in an over-literal manner to social interactions
  28. 28. In their review of research on development of Asperger’s Disorder Gutstein & Whitney (2002) found: • Social competence is major impairment in Asperger’s • Key deficit is experience-sharing relationships • This process develops in manner different from attachment & instrumental interactions • Attachment issues would likely be more consistent with Reactive Attachment Disorder
  29. 29. From a genetics perspective, autism is a heterogeneous disorder on both the phenotype & genotype levels • Review of research is in Chen et al (2012)
  31. 31. Anckarsater et al (2006) • Conducted a study of the impact of autism on temperament, character & personality development • Identified autism & ADHD as childhood-onset neuropsychiatric disorders • Studied personality characteristics of 113 adults with autism • Found that autism spectrum disorders were associated with low novelty seeking and low reward dependence
  32. 32. What is reward dependence? • Reflects the degree to which the person responds to cues of social reward • Seen as being an inherited trait • Individuals high in RD tend to be tender-hearted, sensitive, socially dependent, and sociable • Individuals low in RD tend to be practical, tough-minded, cold, socially insensitive, irresolute, and indifferent if alone • Advantage to high RD: sensitivity to social cues which facilitates affectionate social relations and genuine care for others • Advantages to low RD: personal independence and objectivity not biased by efforts to please others
  33. 33. What neurological and personality research says about autism • Autism is caused by neurological problems at a very young age or even prior to birth • Neurological aspects of autism lead to low Reward Dependence • This leads person to have a low response level of social reward • Individuals with autism do not respond strongly to the social reinforcers (praise, attention) that tend to influence the behaviors of individuals without autism
  34. 34. Teenagers with Autism & Reinforcement • Teenagers with autism face same issues as teenagers without autism • They tend to deal with them differently • What motivates teenagers without autism do not tend to motivate teenagers with autism • It is during teenage years that you tend to see even more the limited effect that social reinforcers have for motivating individuals with autism • Takes some work to determine what can be a reinforcer for teenagers and young adults with autism
  35. 35. Choosing Reinforcers for Individuals with Autism • There is quite a bit of variability in autism • No one reinforcer is going to work for everyone • Asking the person about their interests and what they find rewarding is a good starting point but will likely not be sufficient • Many individuals with autism otherwise will let you know what they find reinforcing • Topics of their perseverations and/or repetitive statements often show what might be reinforcing • You can also use scales and reinforcement surveys to identify specific reiforcers • Most important step here is to find reinforcers likely to be effective for individual
  36. 36. Psychological Effect of Having a Child with Autism • Montes & Halterman (2007) • Mothers of children of autism were likely to report higher stress and mental health problems than mothers in general population • No differences reported for different economic levels
  37. 37. However, Montes & Halterman also found mothers of autistic children were more likely to report: • Having a close relationship with their children • Better coping skills for parents tasks • Less frequent episodes of feeling angry with their children
  38. 38. Billstedt, Gillberg & Gillberg (2011) • Conducted a follow-up study of 108 adults who had been diagnosed with autism 13-22 years earlier: • Majority were still dependent on parents & caregivers for support • General quality of life was deemed to be positive • Needs were identified in areas of occupational & recreational activities • 46% were diagnosed with severe intellectual disabilities, 33% with mild intellectual disabilities and 5% with average IQ
  39. 39. Gender Differences in Autism • Lai et al (2011) reviewed research on autism to find if there are any behavioral differences between the genders. • Found no significant differences in most behavioral areas assessed
  40. 40. Gender Differences (continued) • Females did show more lifetime sensory symptoms, fewer communication problems and more self-reported autistic traits • Authors propose that fewer communication problems could be reason autism is underrepresented in females and diagnosed later for females
  41. 41. Research on anxiety and mood problems in adolescents with autism • Emotional distress increases as social milieu becomes more complex (Sukhodolsky et al, 2008) • Growing self-awareness & desire to form peer relationships without skills to do so increases anxiety and mood problems (Myles, 2003 & Tantan, 2003) • Social & evaluative anxiety often emerge during adolescence for individuals with autism (Kuusikko et al, 2008)
  42. 42. Problems Presented by Youths with Autism • Hurtig et al (2009) studied 43 teenagers with Asperger’s or high-functioning autism • Compared that group to 217 typically developed adolescents • Used Youth Self-Report for teenagers & Child Behavior Checklist for their parents • Autism group identified as having more clinically significant problems • Significantly higher rates of: Social Problems Anxiety Problems Attention Problems Mood Problems
  43. 43. Ooii, Ton, Lim, Ooh & Sung (2011) • Reviewed archival data of 73 younger children (ages 8-12) • Interesting that the outcomes of problems were same as the Hurtig study • 61% were found to have reported significant social problems • When split by DSM diagnoses the children who were identified with problems were split as such: 35.2% had attention problems 33.8% had anxiety problems 31 % had mood problems
  44. 44. Main reasons teenagers & young adults with autism seek out therapy • Social isolation/Social awkwardness • Problems functioning at work or school • Attention problems • Depressed mood • Legal troubles • Anectodal data from my practice and other practices
  45. 45. Psychological Issues faced by teenagers/young adults with autism • Similar to those faced by typical adolescents and young adults • Autism impacts how individuals develop, not necessarily what general issues they face • Struggle for developing independence is a major issue • Fitting in socially is also a major issue
  46. 46. Psychological Issues (continued) • Self-esteem plays a significant role for teenagers & young adults • Sexual development also plays a major role • Issues related to sex is a major issue for individuals with autism given its social context • Some or all of these issues may play major role in reasons individuals seek out psychological treatment
  47. 47. Case Example • 18-year old with Autism • Had been receiving behavioral health services for most of adolescence • Made progress with help of behavior therapy interventions • But what would happen is that he would have increased behavior problems with each new major phase of adolescence
  48. 48. Case Example (continued) • Included moving on to middle school, difficulties in social relationships, increased interest in the opposite gender, starting high school and working to fit in socially when he got to high school • Behavior therapy had to focus on how he implemented approaches to deal with each phase • Most recent issue was how he dealt with grief about moving on after graduating high school
  50. 50. Importance of Assessment in Treating Autism • Baird, Cass & Slonim (2003) • Solid assessment confirms the diagnosis • Important for determining the appropriate treatment • Treatments appropriate for autism might not be most appropriate for other diagnoses
  51. 51. Core Assessment Battery for Autism Should Include: • Parental Interview • Direct Observations of Child • Intelligence Testing • Language Assessment • Adaptive Behavior Measure • Ozonff, Goodling –Jones & Solomon, 2005
  52. 52. Core Assessment Battery (continued) • There is variability in specific measures they suggest for each category • And different measures will require different costs and time commitments
  53. 53. Core Assessment Battery (continued) • For example two measures they suggest for Parental Interview are Autism Diagnostic Interview, Revised (ADI-R) & Social Communication Questionnaire (SCQ): • ADI-R takes anywhere from 1 ½ - 2 hours to administer • SCQ only takes about 10 minutes to administer
  54. 54. Core Assessment Battery (continued) • They also suggest Autism Diagnostic Observation Scale (ADOS) and Child Autism Rating Scale (CARS) for direct observation instruments: • ADOS takes 30-50 minutes to administer • CARS takes 5-10 minutes to administer
  55. 55. Core Assessment Battery (continued) • There also is significant variations in the costs: • Cost for ADOS-2 (available 05/17) is $1,995 for introductory kit • While costs for CARS is only $158 for introductory kit • Cost of ADI-R is $210 for kit that includes materials for 10 assessments • While SCQ is $115 for kit that includes materials for 20 assessments
  56. 56. Core Assessment Battery (continued) • IQ tests will often be the most expensive and time- consuming parts of assessments for developmental &/or intellectual disabilities: • Often important to determine if provider needs to do this testing • Check to see if it can be done elsewhere or if it has already been done • Parents can often request that schools do IQ testing • If IQ testing done within past several years then results can be used for eval and additional IQ testing will not be needed
  57. 57. Core Assessment Battery (continued) • Purpose here is to keep the time commitments and costs of a comprehensive evaluation for intellectual &/or developmental disabilities to a minimum • This will then allow provider to provide accurate diagnoses under the limiting conditions associated with insurance coverage available to people in poverty (e.g. Medical Assistance)
  58. 58. Autism Spectrum Quotient (Baron- Cohen et al, 2006) • Can be used for quick assessment of autism severity • Quantified autistic traits in adolescents • This was an adaption of AQ for Adults (Baron-Cohen et al, 2001) • Rapidly quantified where adolescent is situated from autism to normality • Can be used to help with treatment decisions
  60. 60. Ricard Bromfield in June 11, 2011 edition of HuffPost Healthy Living on the Huffington Post website: “…this past summer I discovered that since its founding in 1979 the Journal of Autism & Developmental Disabilities, a premier journal “devoted to all aspects of autism spectrum disorders, including clinical care and treatment for all individuals, had published 2,262 articles, not one of them focusing on psychotherapy or counseling with a child with Asperger’s”
  61. 61. Bromfield stresses psychodynamic therapy • But some aspects he stresses could also be part of behavior therapy Those aspects include: • Being very accommodating to the individual needs of the client • Slow pace • A lot of waiting • Also involves sparse communication
  62. 62. Type of environments where individuals with autism learn best are ones where: • Physical & temporal environments highlight salient stimuli • Direct teaching & shaping of appropriate behavior are supported • Clear antecedent cues and discriminative stimuli are used • Climate of reinforcement is provided • Heflin & Alberto, 2001
  63. 63. Learning & Autism • Behavior therapy is most often based on learning new skills • Individuals with autism tend to learn best with structured approaches • Identifying how teenagers & young adults with autism learn best can help to increase effectivenss of behavior therapy interventions • One empirically supported approach to helping individuals with autism learn is called the TEACCH method
  64. 64. TEACCH method • Treatment and Education of Autistic and related Communication-Handicapped children • Interventions for helping children and teenagers • Also called ‘‘Structured Teaching’’ • Based on evidence that individuals with autism share a pattern of neuropsychological deficits and strengths
  65. 65. Characteristics of TEACCH method (Mesibov & Shea, 2010) • Relative strength in and preference for processing visual information (compared to difficulties with auditory processing, particularly of language) • Heightened attention to details but difficulty with sequencing, integrating, connecting, or deriving meaning from them • Enormous variability in attention (individuals can be very distractible at times, and at other times intensely focused, with difficulties shifting attention efficiently)
  66. 66. Characteristics of TEACCH method (continued) • Communication problems, which vary by developmental level, but always include impairments in the initiation and social use of language • Difficulty with concepts of time including moving through activities too quickly or too slowly and having problems recognizing the beginning or end of an activity, how long the activity will last, and when it will be finished
  67. 67. Characteristics of TEACCH method (continued) • Tendency to become attached to routines and the settings where they are established, so that activities may be difficult to transfer or generalize from the original learning situation, and disruptions in routines can be uncomfortable, confusing, or upsetting • Very intense interests and impulses to engage in favored activities and difficulties disengaging once Engaged • Marked sensory preferences and aversions.
  68. 68. In a review of research on psychological treatments for autism Howlin (1998) found: • Treatments need to be adapted for meeting individual needs • Functional analysis of problem behaviors is very important • Behavior problems often result from communication problems, social understanding problems &/or perseveration
  69. 69. Functional Assessment • Objective definition of behaviors to address • Collect data in session • Assign homework to collect data outside of session • Use data to identify antecedents & consequences • Identify potential reinforcers • Generate hypotheses about behaviors • Develop & implement behavioral treatment plan
  71. 71. Effectiveness of applied behavioral analysis (ABA) programs for teenagers and young adults: • Vismar & Rogers (2010) reviewed comprehensive ABA programs in classroom & residential setting for teenagers & adults with autistic spectrum disorders • These programs aimed to provide continuum of services in educational, residential & employment programs • Services are delivered in multiple settings
  72. 72. Vismar & Rogers (2010) ----continued • Involve trainers modeling target skills, providing supervised practice opportunities & delivering immediate feedback • Authors determined that there is still insufficient evidence about long-terms outcomes
  73. 73. Miller, N. & Neuringer, A. (2000) • Conducted a study of reinforcement and its effect of repetitive behaviors in teenagers & adults with autism • 5 adolescents w/autism, 5 adult controls & 4 child controls received rewards for varying their responses while playing a computer game • Study focused on repetitive behaviors and how this can result in lack of reinforcement
  74. 74. Miller, N. & Neuringer, A. (2000)---- continued • Authors addressed whether increased variability of responses could then decrease their use of repetitive & stereotypal behaviors • Variability in all groups when variability was directly reinforced • Involved reinforcement of alternative behaviors when addressing repetitive behaviors
  75. 75. Effectiveness of Behavioral Therapy with Teenagers • White, E.R. et al (2011) • Used prompting & reinforcement to teach three pairs of adolescents with autism to use a photographic activity schedule to cooperate in completing multistep tasks • Subjects did not coordinate their activities at baseline • But did increase cooperation after use of prompting & reinforcement • Small pieces of preferred food were used as the reinforcers
  76. 76. White et al (2009) • Studied a cognitive-behavioral treatment program for anxious teenagers diagnosed with autistic spectrum disorders • Treatment involved individual therapy, group social skills training and family training • Called Multi-Component Integrated Treatment (MCIT) • Manualized-Based Treatment • Reduced anxiety in 3 of the 4 subjects who took part in this pilot program
  77. 77. White et al (2010) • Expounded on that treatment program with another cognitive-behavioral treatment program for anxiety in adolescents with autism • Changed name and called that program Multimodal Anxiety & Social Skills Intervention (MASSI) • One of few programs focused on treating anxiety in teenagers with autism as most others focused on younger children
  78. 78. Essential elements of MASSI • Focus on parent & family involvement • Regular practice • Immediate, direct & specific feedback is provided • Emphasis on corrective & positive social learning experiences • Modeling new skills
  79. 79. Parent & Family Involvement • Helping parents accept & understand diagnosis • Strengthening family supports system to compensate for lack of support outside of family • Encouraging adolescent to practice new skills at home • Cognitive-behavior therapy with parent involvement has been found to be superior to other types of cognitive-behavioral therapy (Sdvanoff, 2005)
  80. 80. Regular Practice in MASSI • Helps with generalizing skills • Also addresses problems with context- dependent learning • Treatment involves ample use of role-play & exposure exercises • Parents are encouraged to help adolescent practice at home & in community
  81. 81. MASSI therapists • Provide immediate, direct & specific feedback • Bother MASSI therapist & family members provide feedback on skills • Immediate feedback helps to address difficulties associated with autism • Some of those difficulties include: failure to pick up on subtle cues, difficulties with sustained attention & difficulties distinguishing essential from irrelevant details
  82. 82. Emphasis in MASSI on corrective, positive social learning experiences • Focus on creating supportive environment • Addressing ways to help adolescents feel safe in trying new skills • Time dedicated to group sessions with other teens who have autism to help build cohesion • Helps address years of social rejection that these teens have experienced
  83. 83. Modeling new skills is important part of MASSI • Modeling by therapist in individual sessions • Modeling by peer tutor in group component • Model demonstrates what should be done in given situation • Model also attempt to explicitly state what they are feeling & doing during modeled skill
  84. 84. Structure of MASSI treatment program • Individual therapy • Group treatment • Parent education & training
  85. 85. Other information about MASSI • Using individual therapy, group treatment & parent training helps with generalization • Also helps with individuation of the treatment • Initial feedback from program participants has been positive • No conclusive research findings yet on effectiveness of program
  86. 86. Case Example • 14 year old male with PDD NOS • Particular difficulty with anger directed toward parents • Also anger directed towards babysitter • Met with teenager and parents • Focus on helping teenager learn better anger management skills but also helping parents learn better ways of addressing his behaviors
  87. 87. Case Example (continued) • Worked with teenager and parents on what consequences should be for his behaviors • Got input from parents and also from teenagers on how parents should address his behaviors • This collaborative approach seemed to help with effectivess of behavioral interventions parents used
  88. 88. Collaborative Problem Solving • From Ross Greene’s 2005 book “The Explosive Child” • Greene has written about effectiveness of this approach for different populations, including teenagers with autism • Effective way of helping parents and teenagers work on ways of addressing problems
  89. 89. Collaborative Problem Solving (continued) • Basic approach involves identifying problem and then getting input from both teenager and parents on what should be done about the problem • They then work together on plan for addressing the problem • Can be helpful for teenagers with autism since they often may feel they are left out of discussion of what to do about problems they face
  90. 90. Lang et al (2010) • Review study of cognitive-behavioral treatment for anxiety in teenagers & adults with autism • Reviewed nine studies addressing of anxiety in autistic spectrum disorder using cognitive- behavioral therapy • Found cognitive-behavioral therapy was effective when adding components typically associated with applied behavior analysis
  91. 91. Lang et al (2010)----continued • Two of the main components they addressed were systematic prompting & differential reinforcement • Systematic Prompting: use of physical and/or verbal prompts in structured way • Differential Reinforcement: use of reinforcement to increase frequency of behaviors that are incompatible with the problem behaviors
  92. 92. Case Example • 15-year old male with Asperger’s • Main problems include inappropriate social comments and anger management • Significant problems in weeks prior to therapy with regards to him saying things that embaressed his peers • Also yelled frequently at his parents during even small disagreements
  93. 93. Case Example (continued) • Parents helped to set up reinforcement chart where he could earn rewards for choosing more appropriate anger management and social skills • Also focused on skills that would be more effective alternatives to skills he had been choosing to use • Helped decrease frequency and severity of problem behaviors
  94. 94. Social Skills Programs • Williams et al (2007) studied social skills programs the showed promise for benefitting children & adolescents • Did not find any one program that was more effective than others • Did identify aspects of programs they studied that contributed to effectiveness of programs
  95. 95. Social Skills Programs----continued • Those aspects included increasing social motivation, increasing social interactions, improving appropriate social responding, reducing interfering behaviors and promoting skills generalizations • Authors then went into specific steps that contributed to effectiveness of each general aspect they covered
  96. 96. Increase Social Motivation • Foster self-awareness & self-esteem • Develop nurturing & fun environment • Intersperse new skills with previously mastered skills • Start with simple, easily learned skills
  97. 97. Increase Social Interactions • Make social rules clear & concrete • Model age-appropriate initiation strategies • Use natural reinforcers for social situations (e.g. follow individual’s communication lead & interest level) • Teach simple social scripts for common situations
  98. 98. Improve Age-Appropriate Social Responding • Teach social response scripts • Reinforce response attempts • Use modeling & role-play to teach skills
  99. 99. Reduce Interfering Behaviors • Make teaching structured & predictable • Differentially reinforce positive behaviors
  100. 100. Promote Skill Generalization • Involve parents in training • Use homework assignments as way to have individuals practice skills between sessions
  101. 101. Behavioral Interventions to increase independence • Hume, Loftin & Lantz, 2009 • Most successful interventions targeting increased independent skills emphasize a shift in stimulus control from continuous adult management (e.g., paraprofessional support) during instruction to an alternative stimulus. • The alternative stimulus then provides cues and information about expectations related to behavior and/or social skills
  102. 102. Increasing Independence (continued) Three focused interventions that incorporate this stimulus shift and have proven effective in increasing student engagement while simultaneously decreasing adult prompting are: • Self-monitoring, • Video modeling • Individual work systems
  103. 103. Self-Monitoring • Individual is taught to discriminate and to make a record of the occurrence or nonoccurrence of a target behavior • Increases independence because the individual is the agent of the intervention (as opposed to a teacher or another adult) • In order to self-monitor, an individual must pay adequate attention to his or her own behavior, the conditions under which these behaviors occur and the immediate and distal effects that are produced
  104. 104. Self-Monitoring (continued) • When individuals self-monitor, they attend to select aspects of behavior on which they may ordinarily not focus which can, in turn, re-focus on the most salient elements of behavior • Self-monitoring interventions can be designed to increase the incidence of desired behaviors or to reduce problem behaviors
  105. 105. Self-Monitoring (continued) • Findings from various studies such as these indicate that even core features of autism, such as social functioning, can be improved with the use of interventions that incorporate self- monitoring • In addition, increases in positive behavior that occurred because of self-monitoring were often accompanied by collateral reductions in undesired behavior • This included reductions in self-stimulatory and repetitive/stereotypic behavior
  106. 106. Video Modeling • Can be used to teach skills using minimal adult prompting and interaction • A model performs the target skill while being videotaped • Professionals or peers can serve as models, or the person with autism can serve as his or her own model on the video
  107. 107. Video Modeling (continued) • All prompts are edited out of the video so that the person is seen performing the skill independently • Modeling videos are typically 2–4 min in length • They are watched by the person with autism, often times repetitively • Person with autism can watch the videos alone and as frequently as necessary to acquire the skill
  108. 108. Video Modeling (continued) • Then the viewer is given the opportunity to imitate the skill observed on the video in real-life contexts • Video modeling is particularly well-suited for people with autism since they are usually better able to process and remember visual information compared to material presented verbally
  109. 109. Individual Work Systems • Involves structured teaching as as addressed in the TEACCH system • Emphasizes visual supports • Aims to increase and maximize independent functioning and reduce the frequent need for consequences and/or prompting • Individual work system is defined as a visually organized space where individuals independently practice skills that have been previously mastered • Could be classroom or psychological therapist’s office
  110. 110. A work system visually communicates at least four pieces of information to the individual: • Tasks the individual is supposed to do • How much work there is to be completed • How the individual knows he/she is finished (progress towards goal) • What to do when he/she is finished
  111. 111. Individual Work Systems (continued) • Practice of providing visual sequences of activities (i.e., photographs or icon representations) for students with autism to complete has been proven effective • Visually presenting the sequence of activities enhances the individual’s ability to predict upcoming activities, and provides a consistent strategy for gathering information about what will occur during independent situations
  112. 112. Individual Work Systems (continued) • Deliberate practice of previously mastered skills that occurs through the use of an individual work system is an important step towards generalization across contexts and provides necessary practice to help students perform tasks automatically, quickly, and independently
  113. 113. Cognitive Restructuring • Can be useful for treatment of depression in teenagers and young adults with autism • Attwood (2008) • Focuses on correction of unrealistic thinking • Particularly useful with Aperger’s because of emphasis on logic & evidence • Challenge unrealistic beliefs with facts & logic • Establish evidence for different ways of thinking about situations • Create appropriate & inappropriate responses to problem situations
  114. 114. Types of Negative Thinking for Teenagers/Young Adults with Autism • “There in only one correct way to do everything” • “I must have a lot of friends in order to be happy” • “Making friends means going to parties and going out a lot” • “If I am picked on there must be something wrong with me”
  115. 115. Negative Thinking (continued) • “It is not OK to be different from other people” • “If I have an opinion about something or someone I must express it” • “People who are popular always have good social skills to imitate” • “If I am upset about something then that means something went wrong”
  117. 117. Hoch, Taylor & Rodriguez (2009) • Studied behavioral interventions with teenagers • Used prompting & reinforcement to help teenagers seek assistance • Focused on increasing the frequency with which they asked for assistance if lost • Used cell phones as prompts • Results indicated increased use of effective steps for asking for assistance after use of prompting & reinforcement to teach those skills
  118. 118. Similarly, Taylor et al (2004) used pagers with teenagers • Study involved 3 teenagers with autism • Used the pagers as a prompt to use communication card to get help when lost • Tangible rewards were used to initially teach the skills • Verbal praise was used as a reinforcer during the generalization phase • Results indicated increased use of communication card to get help when lost
  119. 119. HANDS Project (Ohstrom, 2011) • Helping Autism-Diagnosed Teenagers Navigate & Develop Socially • Research Project • Involves creation of an e-learning tool set • This set of tools for electronic devices like smart phones and tablets can be used to support social development for teenagers
  120. 120. HANDS Project (continued) • Purpose of HANDS software was to help increase effectiveness of previously developed software • Focus was on increasing effectiveness of tools by allowing students and their teachers to individualize the software to the studen’s needs • Research studying initial prototype found wide variety of effectiveness & use. • Some teenagers used frequently and found it helpful while others did not • Project continues to be in the development stage
  121. 121. HANDS Project involves five main functions: • Handy Interactive Persuasive Diary: helps teenager in scheduling his or her daily life • Simple Safe Success Instructor (SSSI): presents social stories designed to help teenager learn what behavioral changes are effective for dealing with problematic situations
  122. 122. HANDS Project (continued) • Personal Trainer: also presents social stories to help teenager learn what behaviors are effective for handling problem situations • Individualizer: allows teenager to individualize the appearance of the HANDS software • Sharing Point: allows teachers to share their experience with HANDS software
  123. 123. CONCLUSION • Autism is a neurodevelopmental disorder • Impacts on brain development prenatally or during early childhood • Continues to impact on how individuals respond to issues throughout their lives • Chronic stress can impact on how autism develops in teenage and adult years • Teenagers and young adults with autism face similar issue as typically developed individuals
  124. 124. CONCLUSION (continued) • Autism impacts how the individuals responds to those issues • Independence is a very important issue for these individuals • Solid assessment is important for developing effective treatment plan • Behavior therapy can help individual develop more effective skills for handling limitations and stressors