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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 Answer Booklet | Table of Contents | Autism
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Motivation
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).

Self-Management
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
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 Answer Booklet.

 
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Gender differences in self-reported camouflaging in autistic and non-autistic adults
Autism, Ahead of Print.
Social camouflaging describes the use of strategies to compensate for and mask autistic characteristics during social interactions. A newly developed self-reported measure of camouflaging (Camouflaging Autistic Traits Questionnaire) was used in an online survey to measure gender differences in autistic (n = 306) and non-autistic adults (n = 472) without intellectual disability for the first time. Controlling for age and autistic-like traits, an interaction between gender and diagnostic status was found: autistic females demonstrated higher total camouflaging scores than autistic males (partial η2 = 0.08), but there was no camouflaging gender difference for non-autistic people. Autistic females scored higher than males on two of three Camouflaging Autistic Traits Questionnaire subscales: Masking (partial η2 = 0.05) and Assimilation (partial η2 = 0.06), but not on the Compensation subscale. No differences were found between non-autistic males and females on any subscale. No differences were found between non-binary individuals and other genders in either autistic or non-autistic groups, although samples were underpowered. These findings support previous observations of greater camouflaging in autistic females than males and demonstrate for the first time no self-reported gender difference in non-autistic adults.
Defining the core components of Family Navigation for autism spectrum disorder
Autism, Ahead of Print.
This study aimed to define the core components of Family Navigation for autism spectrum disorder, a promising intervention to reduce disparities in care for this population. Teams from four trials of Family Navigation for autism spectrum disorder completed the Template for Intervention Description and Replication checklist to outline intervention components. Through intervention component analysis and qualitative synthesis, we identified 11 core components across three domains: Training and Supervision, Navigator Tools, and Navigator Activities. We discuss the importance of identifying these core components and implications for future research and practice.
Varied treatment response in young children with autism: A relative comparison of structured and naturalistic behavioral approaches
Autism, Ahead of Print.
Heterogeneity of treatment response is common in children with autism spectrum disorder. Thus, many providers vary the intervention used based on child characteristics and learning domain. An improved understanding of how to match treatments to different children and domain areas may enhance efforts to individualize treatment and improve treatment response. This study evaluated the relative efficacy of discrete trial training and pivotal response training for teaching young children at risk for autism spectrum disorder receptive and expressive language, play, and imitation skills. Using a single-subject adapted alternating treatments design, children received both the treatments for 12 weeks. Data were collected during treatment and at 3-month follow-up. All participants acquired target skills in both treatments and demonstrated some generalization, maintenance, and spontaneous skill use. Pivotal response training and discrete trial training were each more effective for some children and domains. The results suggest that early rates of learning may be predictive of longer-term treatment response and useful in informing treatment decisions.
A cross-sectional descriptive analysis of portrayal of autism spectrum disorders in YouTube videos: A short report
Autism, Ahead of Print.
Professionals have expressed concerns about the quality of autism-related information available from Internet-based sources. The purpose of this study was to examine the source, content, usability, and actionability of autism spectrum disorder–related information contained in 100 different videos directed to families of children with autism spectrum disorder uploaded to YouTube. Upload sources were identified, and video content was coded. Understandability and actionability of the videos were examined using Patient Education Materials Assessment Tool for Audiovisual Materials. The collective number of views of the videos was almost 100 million. The length of videos was 691.17 min (i.e. 11.5 h) with the shortest video being 30 s and the longest video being 37.36 min. The YouTube videos related to autism spectrum disorder covered a range of issues, although much of the content was focused on signs and symptoms. No difference in content reporting was noted based on sources for most categories, although differences were noted in some categories (e.g. professionals mentioned diagnosis and resources more frequently). Poor understandability and actionability scores (i.e. below 70%) were reported for all videos regardless of video source. However, the videos generated by the professionals were superior in terms of understandability. Study implications and recommendations for further research are discussed.
Parent couples’ participation in speech-language therapy for school-age children with autism spectrum disorder in the United States
Autism, Ahead of Print.
This study examined parent couples’ participation in and satisfaction with speech-language therapy for school-age children with autism spectrum disorder in the United States. Responses from 40 father–mother couples (n = 80 parents) were examined across therapy components (i.e. parent–therapist communication, assessment, planning, and intervention). Descriptive frequencies, chi-square tests, intraclass correlations, and dyadic multilevel modeling were used to examine participation across fathers and mothers and within parent couples. Compared to mothers, fathers communicated less with therapists and participated less in assessment and planning. Fathers also had lower satisfaction than mothers with parent–therapist communication and planning. Although few parents participated in school-based therapy sessions, 40% of fathers and 50% of mothers participated in homework. However, few parents received homework support from therapists. Results are discussed in terms of clinical implications for interventionists to more effectively engage both fathers and mothers in family-centered speech-language therapy for school-aged children with autism spectrum disorder.

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