Lecture 2

Question 1

ASD in DSM-5

Answer 1

1. persistent deficits in social communication and interactions across multiple contexts
2. restricted, repetitive patterns of behaviours or activities
   - symptom severity/intensity can vary extensively

Question 2

Early signs of ASD

Answer 2

• communication-interaction: lack of responsiveness
• repetitive behaviours: hand flipping, tiptoeing, stimming
• aggressiveness

Question 3

Prevalence and related symptoms of ASD

Answer 3

• 1-2% in toddlers and children
• more boys diagnosed than girls
• co-morbidities: ADHD, symptoms of anxiety and depression, sleep disorders
• secondary symptoms: self harm (head banging), aggressiveness, tantrums -> have a communicative function (something is wrong, I feel overstimulated)
• worldwide increase in prevalence of children being diagnosed

Question 4

ASD onsets in early development

Answer 4

• neurodevelopmental disorder caused by a combination of genes and environmental factors
• diagnosis in toddlerhood has been well documented (first signs detectable at 6 months old)
• ASD is often associated with developmental deficits and delays, comorbidities, and secondary symptoms which all produce psychosocial impairment

Question 5

Need for accurate early intervention

Answer 5

• challenge: multitude of clinical presentations
• functioning of children with ASD can range from highly skilled to severely challenged

Question 6

Goal of intervention

Answer 6

• improve functioning and ability to lead satisfying lives in the community
• reduction in symptoms -> less repetitive behavior
• developmental improvements -> child learns to speak
• reduction in problem behaviors -> less tantrums
• better coping with daily expectations -> attending regular education
• important to match intervention with the goals of the child and parents

Question 7

First interventions (poor outcomes)

Answer 7

• intense and radical (i.e. ECT, strict dietary restrictions)
• little to no early intervention
• almost all were placed in mental institutions by adolescence, 50% remained non verbal, 1.5% achieved ‘normal’ functioning

Question 8

Behavioural Interventions (Skinner)

Answer 8

• principle of reinforcement: behaviour is dependent upon its consequences
• antecedent -> behaviour > consequence
• reinforcement: if the consequence is good, the behavior will be repeated (positive vs negative reinforcement)
• punishment: if consequence of the behavior is bad, behavior will likely not be repeated (positive vs negative punishment)
• extinction: by removing the reinforcer, behavior will fade and eventually dissappear

Question 9

Applied Behavioural Analysis (ABA) Principles

Answer 9

1. behaviours are affected by their environment
2. behaviours can be strengthened or weakened by their consequences
3. behaviour changes are more effective with positive instead of negative consequences
4. behaviours need to be reinforced or disciplined for socially significant changes

Question 10

Lovaas: ABA early work

Answer 10

• focus on punitive aspects (electric shocks omfg this is acc so bad)
• intervention setting: impersonal, empty room
• no family involvement during interventions
• later also a focus on primary reinforcers such as food and affection to modify behaviours

Question 11

Lovaas: ABA Later work

Answer 11

• early and intensive behavioural intervention (EIBI)
• compared children with 40hrs of weekly 1-1 therapy with children with less than 10 hours
• these children received discrete-trial training (DTT)

Question 12

DTT

Answer 12

• important skills are taught in a repeated and brief fashion with a specific instruction (discriminative stimulus)
• skills are divided into small components, taught one at a time
• operant techniques (ABA principles) are applied to establish learning skills and to eliminate atypical behaviour
• skill development is tracked

Question 13

Results of Lovass’ later work

Answer 13

• intensive treatment: 47% achieved ‘normal’ intellectual and educational functioning, and ‘only’ 10% were intellectually disabled
• light treatment: 2% achieved ‘normal’ intellectual and education functioning, 45% were mildly intellectually disabled and placed in language delayed classed, and 53% were severely intellectually disabled and placed in classed for children with ASD

Question 14

Skills taught to children with ASD

Answer 14

• Social skills (e.g., sharing, turn-taking)
• Communication skills (e.g., using words to get what you want)
• Play (e.g., joint attention)
• Behavior (e.g., waiting, emotion regulation)
• Motor skills (e.g., fine/gross)
• Cognitive skills (e.g., imitation)
• Adaptive skills (e.g., dressing, feeding, toileting)

Question 15

Naturalistic Developmental Behavioural Interventions (NDBI)

Answer 15

• represent merging of applied behavioural and developmental sciences
• learning targets (developmental tasks)
• learning contexts (natural settings, bidirectional interactions between child and adults
• learning strategies (motivation comes from own interests and preferences)
• learning science (evidence based practice)

Question 16

Emergence of more sophisticated models of early developmental learning
processes involved in communication, language, and social learning

Answer 16

Joint attention (the shared focus of individuals on an object to share information)
as a key precursor of language development, social interactions
* Imitation (~ Theory of Mind) as a key precursor of language development, social
interactions, and many other skills
* Children are active (rather than passive) learners (‘hypothesis-testers’)
* Social relationships (also with therapist) are essential contexts for learning
* Affective engagement facilitates learning

Question 17

Early ABA interventions are effective in teaching skills, but

Answer 17

• Lack of generalization: newly learned skills are limited to specific environments and
  circumstances (clinic versus home environment)
• Lack of spontaneity: highly-structured teaching approaches
• Overdependence on prompts
• Avoidance behaviors: child is not internally motivated
• Extremely time and labor intensive

Question 18

Core Components of NDBI’s

Answer 18

• ABA as core, manualized, measurement of progress
• focus on generalization of acquired skills (teach skills in natural settings)
• environmental arrangement to facilitate interaction
• prompting and then fading - learn just beyond present knowledge (zone of proximal development)
• modeling by therapist, encourage imitation by child
• broadening the attentional focus to counter stimulus over selectivity
• watch lecture for examples

Question 19

Examples of NDBI’s

Answer 19

• incidental teaching (IT)
• enhanced milieu training (EMT)
• reciprocal imitation training (RIT)
• project ImPACT
• Joint Attention Symbolic Play Engagement and Regulation (JASPER)

Question 20

Pivotal Response Treatment (PRT)

Answer 20

• focused on targeting ‘‘pivotal’’ areas/skills/responses within a child’s natural environment to support language development and social interaction
• focuses on increasing motivation to interact with others which underlies -> self management/regulation, self-initiate social interactions
• how to increase motivation -> child-selected stimulus materials, direct and natural reinforcers, play based
• for children between 2-6
• family involvement in both the creation and implementation of the intervention: trainers and parents work together to create goals for the child, parents are trained to deliver PRT at home

Question 21

Early Start Denver Model (ESDM)

Answer 21

• based on ABA, PRT and social motivation hypothesis
• focus: building close relationships
• through play and imitation
• facilitate language and social development
• for infants and toddlers
• more structured than PRT
• impaired sensitivity to reward and value of social stimuli -> reduced attention to and interaction with social stimuli -> impairments in communication and social-emotional skills

Question 22

Effects of different deliveries of ESDM

Answer 22

• intensive delivery at home by trained therapist: large IQ improvements, adaptive behaviour, language and ASD severity improvements
• parent coaching: single case studies with positive effects on language, play, imitation and two RCT’s with mixed findings
• preschool/day care delivery: improvements in developmental rate and language skills
• adapted for use with infants: positive effects but v small sample

Question 23

Long term outcomes for ESDM

Answer 23

• ESDM or community treatment was
  delivered to children between 18 and
  30 months
• Follow-up study when children were
  6 years old.
• ESDM group maintained the gains made in early intervention in overall intellectual
  ability, adaptive behavior, symptom severity, and challenging behavior.

Question 24

Timing of PRT

Answer 24

• before 3: 95% become verbal
• between 3-5: 85% become verbal
• after 5: 20% become verbal

Question 25

Timing of ESDM

Answer 25

- 12 week parent intervention with infants between 7 and 15 mths - at 36 mths, the treated group had much lower rates of ASD than a similarly symptomatic group who did not enroll in treatment study

Question 26

Dosage of early interventions

Answer 26

- Lovaas (1987): more than 40hrs/week, one-on-one - ESDM: 20hrs/week, one-on-one, for two years - Recommendation by US National Academy of Sciences (2001): > 20hrs/week - Granpeesheh et al. (2009): treatment progress is related to treatment hours - Recent meta-analyses and reviews: no benefit to delivering additional hours (>20hrs/week). Parents’ attendance and adherence may be greater in ‘low’-dose interventions *Costs and benefits on the family must be weighed

Question 27

Barriers to care

Answer 27

- shortage of qualified providers of early intervention for young children with ASD - geographic areas without adequate service availability - challenges in funding for intervention - systems that are underprepared to meet the needs of children from culturally and linguistically diverse populations

Question 28

Less intensive alternatives - parent coaching in ESDM practice

Answer 28

- N = 8; 12 weeks, 1hr/week - parents acquired the strategies by the fifth to sixth hour -children demonstrated sustained change and growth in social communication behavior

Question 29

Less intensive alternatives - parent coaching of PRT

Answer 29

-parents of 16-30 months old toddlers with (suspected) ASD * low socioeconomic status families in rural areas in Canada * 12 weeks Results: * Increased vocal responsiveness and initiations of children * Increased parent self-efficacy

Question 30

Telehealth

Answer 30

- free website with 16 5-minute videos for parents from low resource communities to add simple ESDM practices to their everyday routines - parents: short video lessons, many parent-child videos to watch, ideas to practice, not too much reading, available on smart phone - clinicians: additional support on how to coach parents, webinars, group supervision *importance of joint attention and interaction with children

Question 31

Efficacy trials

Answer 31

- explanatory trials - determine performance of an intervention (component) under ideal and controlled circumstances - usually medium to large effect sizes in interventions for ASD * indicate that there remains a large gap between outcomes observed in community settings and those reported in efficacy trials.

Question 32

Effectiveness trials

Answer 32

- pragmatic trials - determine the performance of an intervention (component) under real world conditions - small to medium effect sizes of ASD interventions

Question 33

Future Directions - Peer-mediated intervention (PMI)

Answer 33

- neurotypically developing peers teach a variety of skills to children with ASD - increases communication and interpersonal skills - increases opportunities to interact

Question 34

Future directions - Sibling-mediation intervention (SMI)

Answer 34

- along with parent-mediated interventions - siblings could support skill generalization - could increase fun, reciprocal play, and learning opportunities