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Autism: Family Life - Tactics for Getting Normal Again
Autism continuing education counselor CEUs

Section 13
Pivotal Areas in Intervention for Families with Autistic Children

CEU Question 13 | CEU Test | Table of Contents | Autism
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Procedures that increase motivation, as defined earlier, have now been reported extensively in the literature. In particular, several antecedent variables have been identified that increase children with autism's responsiveness to social and academic stimuli, while simultaneously decreasing the amount of disruptive behaviors exhibited during interactions (Kern & Dunlap, 1998; R. L. Koegel et al., 1998; Schreibman, Stahmer, & Pierce, 1996). These variables include child choice, task variation and interspersal of maintenance tasks, reinforcement of response attempts, and the use of natural and direct reinforcers.

Child choice is defined as the incorporation of child-preferred or child-chosen materials, activities, topics, and toys into learning opportunities. Although the clinician follows the child's lead, the environment remains structured such that desired target behaviors are incorporated into the activities, while maintaining the child's attention, and decreasing the likelihood that the child will avoid the interactions and engage in disruptive behaviors (cf. Dyer, Dunlap, & Winterling, 1990; Kern et al., 1998; R. L. Koegel et al., 1998; Moes, 1998; Sigafoos, 1998). Motivation can also be improved by varying the task sequencing and interspersing previously mastered tasks with new acquisition tasks during a learning activity (Carr, Newsom, & Binkoff, 1980; Davis, Brady, Williams, & Hamilton, 1992; Dunlap, 1984; Winterling, Dunlap, & O'Neill, 1987). The child thus experiences a higher rate of success, a greater likelihood of reinforcement, and consequently, increased responsivity (R. L. Koegel, Carter, et al., 1998).

Broadening shaping criteria to reinforce the children's appropriate attempts to make social and communicative responses, as compared to a stricter shaping criterion wherein only responses that are as good or better than previous responses are reinforced, has been shown to increase the children's acquisition of language and academic tasks (R. L. Koegel, Carter, et al., 1998; R. L. Koegel & Egel, 1979; R. L. Koegel, O'Dell, & Dunlap, 1988). This may be especially important for acquisition of first words in nonverbal children (R. L. Koegel et al, 1988), particularly because related areas such as phonology, pragmatics, and semantics may not yet be strongly established due to lack of practice of these complex multiple components that comprise appropriate social interactions (cf. Camarata, 1996; Camarata & Leonard, 1986).

Research has shown that incorporating natural reinforcers that are directly and inherently related to the child's response leads to increased motivation, enhanced learning, and more rapid acquisition of the target behaviors (L. K. Koegel & Koegel, 1995; R. L. Koegel, Carter, et al., 1998; McEvoy & Brady, 1988). Use of natural, direct reinforcers can teach the children that there is a direct relation between their response and reinforcement (L. K. Koegel & Koegel, 1995) and may shorten the delay between a response and reinforcement, resulting in the stimuli and reinforcer becoming more salient (Kazdin, 1977; Skinner, 1979).

Incorporating the motivational variables described earlier, as a group, into an intervention approach can significantly improve language, academic, and social functioning, while simultaneously decreasing disruptive behavior in children with autism as well as other populations (Dunlap, Kern-Dunlap, Clarke, & Robbins, 1991; Kern & Dunlap, 1998; L. K. Koegel, Koegel, & Carter, 1998; R. L. Koegel, Dyer, & Bell, 1987; R. L. Koegel, Koegel, & Schreibman, 1991; Moes, 1998; Schreibman et al., 1996).

Multiple Cues
Responsivity to multiple cues is another pivotal area that when changed appears to produce widespread improvements in children with autism. Research has indicated a lack of response to multiple cues, or stimulus overselectivity, in children with autism (Allen & Fuqua, 1985; Bickel, Stella, & Etzel, 1984; Fein, Tinder, & Waterhouse, 1979; Frankel, Simmons, Fitcher, & Freeman, 1984; R. L. Koegel & Schreibman, 1977; Lovaas, Koegel, & Schreibman, 1979; Pierce, Glad, & Schreibman, 1997; Reynolds, Newsom, & Lovaas, 1974; Schreibman, Charlop, & Koegel, 1982; Schreibman, Kohlenberg, & Britten, 1986), which occurs when a child responds to an overlimited portion of cues in the environment or responds on the basis of an irrelevant component of a complex stimulus. Lack of responding to multiple cues can lead to negative sequelae such as learning problems in the areas of language acquisition, social behavior, observational learning, and generalization (Burke, 1991; Dunlap, Koegel, & Burke, 1981; Lovaas et al., 1979; Schreibman et al., 1996). Intervention that teaches children with autism to respond to multiple cues in the environment has been shown to enhance attention to social cues and increase learning and generalization (Burke & Cerniglia, 1990).

Another area that appears to be pivotal for widespread intervention gains is self-management or self-regulation of behavior. Typically developing children acquire increasing autonomy and self-regulation as they mature. In addition, children without disabilities demonstrate widespread generalized use of newly learned behaviors through self-management of responding. However, children with autism often do not appear to develop the necessary self-regulatory behaviors needed to be responsive to the environmental social cues that lead to independence.

Individuals who are not showing widespread generalization of newly learned skills or autonomy of responding can be taught to self-manage behavior. The general procedure involves teaching individuals to discriminate between appropriate and inappropriate behaviors, then to actively record correct responses, and in some cases to administer self-rewards. This procedure can foster generalization of appropriate behaviors across settings and interactions with others while decreasing the need for constant and long-term vigilance by a clinician (Jones, Nelson, & Kazdin, 1977; Kazdin, 1974; Kern, Marder, Boyajian, Elliot, & McElhatten, 1997; R. L. Koegel, Koegel, & Parks, 1995; Pieree & Schreibman, 1994; Stahmer & Schreibman, 1992). Interventions using self-management have been shown to result in increases in personal competence, problem solving, and independence (L. K. Koegel & Koegel, 1995) and have been successful in targeting a variety of behaviors such as stereotypy (R. L. Koegel & Koegel, 1990), social skills (L. K. Koegel et al., 1992; R. L. Koegel & Frea, 1993; Reese, Sherman, & Sheldon, 1984), disruptive behavior (Newman, Tuntigian, Ryan, & Reinecke, 1997), appropriate play (Stahmer & Schreibman, 1992), and academic skills (Harris, 1986). In addition, implementing a self-management program can promote a cycle of increasing positive interactions, as the children leam to self-recruit reinforcement for appropriate behaviors in the natural environment, thus increasing the likelihood of obtaining reinforcement from individuals outside the intervention setting (Baer, Fowler, & Carden-Smith, 1984; Todd, Horner, & Sugai, 1999).

Self-initiations are an additional pivotal area that when targeted tan lead to improvements in social and pragmatic development. Although typically developing children demonstrate a variety of initiations (such as asking questions) in social and learning contexts, children with autism and similar communicative disorders often do not use initiations that lead to such interactions (cf. Hung, 1977; L. K. Koegel, 1995; Paul & Shiffer, 1991; Tagar-Flusherg, 1994; Taylor & Harris, 1995; Wetherby & Prutting, 1984). Strategies that teach children with autism to self-initiate social and teaching interactions may promote learning in language, social skills, and pragmatics (L. K. Koegel, Camarata, Valdez-Menchaea, & Koegel, 1998; L. K. Koegel, Koegel, Shoshan, & McNerney, 1999; Krantz & McClannahan, 1993; Yoder, Warren, & Hull, 1995) and concomitantly lead to decreases in untreated disruptive behavior (Oke & Schreibman, 1990).

Summary of Conceptual Framework
In summary, we have hypothesized that a qualitative impairment in social communicative interaction plays a major role in autism spectrum disorder (L. K. Koegel, Valdez-Menchaca, Koegel, & Harrower, in press). Behaviors in this category that may be evidenced early on, prior to the onset of intentional communication (10-18months), include lack of eye contact, lack of anticipatory movements, lack of head positioning, stereotypic movements, and unusual facial expressions. From an intervention perspective, the disability may be long and well-established when intervention commences. By this time, the aforementioned learned helplessness, or lack of motivation to engage in complex social and academic tasks, may permeate the child's behavior and exhibit itself as a marked lack of motivation. Specifically, the children often do not respond at all to complex social stimuli or exhibit extreme latencies in responding. When pushed, they may engage in disruptive behavior including tantrums, aggression, and self-injury.

Addressing core behaviors during intervention is an emerging strategy in reducing proxy behaviors or symptoms that show an indirect relation with core symptomatology of children with autism. As can be noted in Figure 1, the major or core area in this conceptual framework relates to increasing the child's motivation to engage in social communicative interactions. This involves motivating the child to initiate social interactions, to self-regulate behavior, and to respond to complex interactions involving multiple cues. Thus, specific procedures designed to increase motivation are incorporated into all teaching and learning interactions. Research has shown that addressing this core area may result in large improvements not only in the core areas of social communication, initiations, and self-management but also in many proxy behaviors including reductions in disruptive and stereotypic behavior and improvements in vocabulary and language, speech intelligibility, and play interactions with peers. 

Brief Review of Recent Outcome Studies
In addition to the large number of studies over the past 3 decades showing that children with autism tan learn numerous individual target behaviors, there now is a growing body of literature demonstrating concomitant changes in untreated behaviors following intervention for certain core behaviors as the focus of intervention. Matson, Benavidez, Compton, Paclawskyj, & Baglio (1996) reviewed 251 studies from 1980 to 1996 that utilized behavioral interventions for children with autism. These authors discussed the concept of pivotal behaviors as a growing trend that may decrease the amount of time, effort, and number of behaviors requiring direct intervention while simultaneously increasing the effectiveness of intervention.

The following brief review of outcome studies is divided into (a) examples of studies reporting data on collateral and generalized improvements in multiple observable behavioral symptoms that are characteristic of children with autism and (b) examples of global long-term outcome studies.
- Koegel, Robert, Koegel, Lynn & Erin McNerney; Pivotal areas in intervention for autism; Journal of Clinical Child Psychology; Fall 2001, Vol. 30, Issue 1.

Therapies for Children with Autism Spectrum Disorder:
Behavioral Interventions Update

- Vanderbilt Evidence-based Practice Center. (2014). Therapies for Children with Autism Spectrum Disorder: Behavioral Interventions Update. Agency for Healthcare Research and Quality.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #6
The preceding section contained information about pivotal areas in intervention for autism.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 13
What is the rationale behind the use of natural, direct reinforcers? Record the letter of the correct answer the CEU Test.

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Table of Contents

Impact of a digital Modified Checklist for Autism in Toddlers–Revised on likelihood and age of autism diagnosis and referral for developmental evaluation
Autism, Ahead of Print.
The present study is a single-site quality improvement project within pediatric primary care involving the implementation of a digital version of the Modified Checklist for Autism in Toddlers–Revised. We evaluated the impact of the digital screener on the likelihood of physician referral for a developmental evaluation or autism diagnosis, and the age of the patients at the time of the event. Patients were children 16–30  months old seen for 18 and 24 months’ well-child visits (1279 encounters), who screened positive for risk for autism spectrum disorder on the Modified Checklist for Autism in Toddlers–Revised without a previously documented autism spectrum disorder diagnosis. Comparisons were made between a cohort of children screened with the paper and pencil version of the Modified Checklist for Autism in Toddlers–Revised before the digital version was implemented and a cohort of children screened during the intervention period. Patients were followed until 48 months and referrals were obtained from electronic health records. Patients screened with the digital Modified Checklist for Autism in Toddlers–Revised were five times more likely to be referred for a developmental evaluation. The automatic scoring, risk assessment, and referral decision support features helped to improve screening outcomes. In this clinic, process change to a digital screening method with automatic guidance for next steps improved adherence to evidence-based clinical care.Lay abstractThis was a project in primary care for young children (1–2 years old). We tested a parent questionnaire on a tablet. This tablet questionnaire asked questions to see whether the child may have autism. We compared the paper and pencil version of the questionnaire to the tablet questionnaire. We read the medical charts for the children until they were 4 years old to see whether they ended up having autism. We found that doctors were more likely to recommend an autism evaluation when a parent used the tablet questionnaire. We think that the tablet’s automatic scoring feature helped the doctors. We also think that the doctors benefited from the advice the tablet gave them.
Implementing early intensive behavioral intervention in community settings
Autism, Ahead of Print.
Although research shows early intensive behavioral intervention is efficacious when delivered in university or private intervention centers, little is known about effectiveness or feasibility of disseminating early intensive behavioral intervention to larger communities. The Michigan State University Early Learning Institute was developed to address gaps in distribution of early intensive behavioral intervention to community settings, with an emphasis of serving children and families on Medicaid. This short report describes the Early Learning Institute’s approach and preliminary utilization data among Medicaid families. Results suggest the model has potential for dissemination within community settings and promote utilization among Medicaid children.Lay abstractAlthough research shows early intensive behavioral intervention can be very beneficial for children with autism spectrum disorder when delivered in university or private intervention centers, little is known about the best way to provide early intensive behavioral intervention within the broader community. The Michigan State University Early Learning Institute was developed to address challenges with providing early intensive behavioral intervention in community settings, with an emphasis on serving children and families on Medicaid. This short report describes the approach taken by the Early Learning Institute and reports data regarding enrollment and utilization among Medicaid families. Results suggest the model has potential to be used within community settings and that children on Medicaid are likely to consistently attend their treatment sessions.
Work, living, and the pursuit of happiness: Vocational and psychosocial outcomes for young adults with autism
Autism, Ahead of Print.
Longitudinal data on the functioning of adults referred for possible autism as children are sparse and possibly different from datasets consisting of adult clinical referrals. A total of 123 young adults, mean age of 26, referred for neurodevelopmental disorders in early childhood were categorized into three outcome groups: autism spectrum disorder (ASD) diagnosis at some point and current intelligence quotient (IQ) ⩾ 70 (Ever ASD-Higher IQ), ever ASD and current IQ < 70 (Ever ASD-Lower IQ), and individuals who never received an ASD diagnosis (Never ASD). Independence and well-being were assessed through direct testing, questionnaires, and interviews. Verbal IQ, beyond intellectual disability status, accounted for group differences in employment; autistic features (Autism Diagnostic Observation Schedule Calibrated Severity Score) were uniquely related to adaptive skills and friendships. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, lower well-being and fewer positive emotions were related to ASD diagnosis across IQ. The Ever ASD-Lower IQ group had the highest levels of irritability, hyperactivity, and medications. Families played a major role in supporting adults with and without ASD at all intellectual levels. Realistic ways of increasing independence should be developed through working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence, and autism symptoms across neurodevelopmental disorders.Lay abstractIt is important to better understand how adults with autism are functioning in adulthood. Studies that have tracked individuals across the lifespan can help identify developmental factors influence differences in adult outcomes. The present study examines the independence, well-being, and functioning of 123 adults that have been closely followed since early childhood. Autism diagnosis and cognitive assessments were given frequently throughout childhood and during adulthood. We examined differences between adults who had received an autism diagnosis at some point with higher cognitive abilities (Ever ASD-High IQ) and lower cognitive abilities (Ever ASD-Low IQ), as well as adults who never received a diagnosis of autism in the course of the study (Never ASD). We found that autistic features specifically related to adaptive skills and friendships, and verbal intelligence related to work outcomes. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, adults with ASD tended to have lower well-being and fewer positive emotions. Families played a major role in supporting adults with and without ASD at all intellectual levels. The findings suggest that realistic ways of increasing independence need to be developed by working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence and autism symptoms across neurodevelopmental disorders.
Does implementing a new intervention disrupt use of existing evidence-based autism interventions?
Autism, Ahead of Print.
This study examines how the introduction of TeachTown:Basics, a computer-assisted intervention for students with autism spectrum disorder, influenced teachers’ use of other evidence-based practices. In a randomized controlled trial that enrolled 73 teachers nested within 58 schools, we used three-level hierarchical linear models to evaluate changes in teachers’ use of evidence-based practices across the school year for those who received TeachTown:Basics versus those assigned to control. Both groups received training and implementation support to deliver three well-established evidence-based practices for autism spectrum disorder. Qualitative interviews were conducted with 25 teachers who used TeachTown:Basics to better understand their experience. Compared with teachers in the control group, teachers in the TeachTown:Basics group reported significantly less growth over the 9-month period in their use of evidence-based practices that require one-to-one instruction (ps < 0.05), but no difference in their reported use of evidence-based practices that do not involve one-to-one instruction (p = 0.637). Qualitative interviews indicated that teachers viewed TeachTown:Basics as an effective substitute for one-to-one instruction because it was less burdensome, despite the lack of support for TeachTown:Basics’ effectiveness. Before introducing new practices, education leaders should carefully consider both evidence of effectiveness and the potential impact on the use of other evidence-based practices.Lay abstractInterventions for children with autism spectrum disorder are complex and often are not implemented successfully within schools. When new practices are introduced in schools, they often are layered on top of existing practices, with little attention paid to how introducing new practices affects the use of existing practices. This study evaluated how introducing a computer-assisted intervention, called TeachTown:Basics, affected the use of other evidence-based practices in autism support classrooms. We compared how often teachers reported using a set of evidence-based practices in classrooms that either had access to TeachTown:Basics or did not have the program. We found that teachers who had access to the computer-assisted intervention reported using the other evidence-based practices less often as the school year progressed. Teachers also reported that they liked the computer-assisted intervention, found it easy to use, and that it helped overcome challenges to implementing other evidence-based practices. This is important because the computer-assisted intervention did not improve child outcomes in a previous study and indicates that teachers may use interventions that are appealing and easier to implement, even when they do not have evidence to support their effectiveness. These findings support the idea of interventions’ complexity and how well the intervention fits within the classroom affect how teachers use it and highlight the need to develop school-based interventions that both appeal to the practitioner and improve child outcomes.
Autistic peer-to-peer information transfer is highly effective
Autism, Ahead of Print.
Effective information transfer requires social communication skills. As autism is clinically defined by social communication deficits, it may be expected that information transfer between autistic people would be particularly deficient. However, the Double Empathy theory would suggest that communication difficulties arise from a mismatch in neurotype; and thus information transfer between autistic people may be more successful than information transfer between an autistic and a non-autistic person. We investigate this by examining information transfer between autistic adults, non-autistic adults and mixed autistic-with-non-autistic pairs. Initial participants were told a story which they recounted to a second participant, who recounted the story to a third participant and so on, along a ‘diffusion chain’ of eight participants (n = 72). We found a significantly steeper decline in detail retention in the mixed chains, while autistic chains did not significantly differ from non-autistic chains. Participant rapport ratings revealed significantly lower scores for mixed chains. These results challenge the diagnostic criterion that autistic people lack the skills to interact successfully. Rather, autistic people effectively share information with each other. Information transfer selectively degrades more quickly in mixed pairs, in parallel with a reduction in rapport.Lay abstractSharing information with other people relies on the ability to communicate well. Autism is defined clinically by deficits in social communication. It may therefore be expected that autistic people find it difficult to share information with other people. We wanted to find out whether this was the case, and whether it was different when autistic people were sharing information with other autistic people or with non-autistic people. We recruited nine groups, each with eight people. In three of the groups, everyone was autistic; in three of the groups, everyone was non-autistic; and three of the groups were mixed groups where half the group was autistic and half the group was non-autistic. We told one person in each group a story and asked them to share it with another person, and for that person to share it again and so on, until everyone in the group had heard the story. We then looked at how many details of the story had been shared at each stage. We found that autistic people share information with other autistic people as well as non-autistic people do with other non-autistic people. However, when there are mixed groups of autistic and non-autistic people, much less information is shared. Participants were also asked how they felt they had got on with the other person in the interaction. The people in the mixed groups also experienced lower rapport with the person they were sharing the story with. This finding is important as it shows that autistic people have the skills to share information well with one another and experience good rapport, and that there are selective problems when autistic and non-autistic people are interacting.

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