The New York State Department of Health (DOH) recently released a report recommending intensive behavioral intervention as the most effective treatment for children with "autistic disorder" and "pervasive developmental disorder not otherwise specified (PDD-NOS)." This report is the outcome of a two-year effort to develop clinical practice guidelines for the Early Intervention program in New York State. (Editor’s note: In Connecticut, this program is known as the "Birth to Three System.")

The guidelines were developed by an independent, multi-disciplinary panel of topic experts, clinicians, educators, and parents. The DOH panel used the same methodology and guideline format that have been used in recent years by the Agency for Health Care Policy and Research, a part of the United States Public Health Services.  

According to a May 28, 1999 article in the New York daily newspaper Newsday, "The state panel that developed the guidelines says studies support the effectiveness of the strategy, called Applied Behavior Analysis or ABA, and that there is no scientific evidence that other approaches, such as sensory or auditory integration, music therapy and facilitated communication, work."

The report specifically recommended that "intensive behavioral intervention programs include as a MINIMUM (emphasis in original) approximately 20 hours per week of individualized behavioral intervention using applied behavior analysis (ABA) techniques (not including time spent by parents)."

The report further noted that "the precise number of hours of behavioral intervention vary depending on a variety of child and family characteristics. Considerations in determining the frequency and intensity of intervention include age, severity of autistic symptoms, rate of progress, other health considerations, tolerance of the child for the intervention, and family participation."

For further information regarding this report, which is titled "Clinical Practice Guideline: The Report of the Recommendations. Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children (Ages 0-3 Years)," you can contact: New York State Department of Health, Early Intervention Program, Corning Tower Bldg., Room 208, Albany, New York, 12237-0618; 518-473-7016.

(Mareile Koenig, Ph.D., CCC-SLP, CBA/PA)

 Have you ever wished for a state-of-the-art manual that would describe the fundamentals of intensive behavioral intervention in plain English with:

 

• clear guidelines

• concrete examples

• a behaviorally-defined developmental curriculum

• sensitivity to individual differences

• techniques for assessing and documenting progress

• an absence of distracting references within the text?

Have you dared to wish that such a manual be written by professionals whose credibility and ideas are validated not only by a peer-reviewed publication record but also by a substantial history of world-class, hands-on experience in treating children with autism? If so, you should order Ron Leaf and John McEachin’s (both Ph.D.s) new book A Work in Progress: Behavior Management Strategies and a Curriculum for Intensive Behavioral Treatment of Autism (DRL Books, L.L.C., New York, 1999). What you’ll get (for a mere $42.95) is a marvelous 400-page manual summarizing procedures with proven effectiveness for teaching children with autism and written in the spirit of parent-professional partnership. Need more information? Read on…

Given all the complexities and challenges presented by individual children on the autism spectrum, no single book can possibly cover every essential detail. However, from a behavioral/educational perspective, A Work in Progress offers a substantial piece of the foundation. In the words of its talented and well-known authors, the book seeks to "provide a road map and enough detailed examples that people who work with autistic children might develop a good understanding of the [behavioral] teaching process." It is organized into 3 parts: 1) Behavioral Strategies for Teaching and Improving [the] Behavior of Autistic Children, 2) the Autism Partnership Curriculum for Discrete Trial Teaching with Autistic Children, and 3) an Appendices section consisting of seven forms that can be used in setting up and implementing a behavioral intervention program.

The section on behavioral strategies is divided into 12 chapters written by Ron Leaf, John McEachin, Jamison Dayharsh, and Marlene Boehm. Chapter 1 provides a general overview of intensive behavioral intervention (IBI) for children with autism. A brief summary of the historical foundations is followed by a description of nuts and bolts issues, including curriculum development, the number of hours of training, the teaching format, various settings in which teaching takes place, stages in the evolution of therapy, assessment, and guidelines for program effectiveness. Chapter 2 presents special considerations for older children and adolescents.

Chapter 3 addresses the all-important issue of reinforcement - - the bottom line of any effective behavioral approach. This topic is introduced by clarifying misconceptions about the use of reinforcement. It is followed by important tips for the identification of reinforcers, and by a discussion of other reinforcement issues, including types of reinforcers, schedules of reinforcement, guidelines for the use of reinforcement, and specific examples of differential reinforcement.

Chapters 4 to 10 offer excellent guidelines for understanding and addressing behavioral challenges common to children on the autism spectrum. Included here are the elements of positive behavioral support systems for reducing disruptive and self-stimulatory behaviors, and strategies for the normalization of sleeping patterns, toilet training, and the reduction of food selectivity.

Chapters 11 and 12 address strategies for shaping play skills, social skills, and social play. Overall, the chapters in this section offer succinct, behavioral guidelines and real-world examples for increasing adaptive behaviors and reducing the maladaptive behaviors that frequently accompany autism.

The second part of A Work in Progress is The Autism Partnership Curriculum. It is introduced by guidelines that shape each instructional session. This is followed by an in-depth description of the discrete trial protocol. Here the reader will find information about the components of a discrete trial, strategies for maintaining a child’s attention, guidelines for maximizing progress, and a checklist for planning generalization training. Clear examples are offered throughout to illustrate specific points.

The curriculum itself includes about 60 skill sequences. These sequences are tied to 5 skill domains: pre-academic, communication/language, academic, social, and self-help. Each skill sequence is accompanied by general goals, teaching guidelines, special considerations unique to the sequence, and specific methods for achieving each skill within the sequence.

The appendices in A Work in Progress include a variety of forms needed to organize the various aspects of a child’s IBI program. Appendix A is a 28-page assessment checklist. It represents all skill sequences within the curriculum and provides spaces for documenting a child’s performance at 3 different observation points. Codes are provided for ease of documentation. It’s an excellent tool. Appendices B to E offer additional forms that are useful for documenting, summarizing and analyzing information during a program’s implementation. There is also a very worthwhile "Performance Evaluation" form for documenting the proficiency of a teacher’s performance.

Several aspects of content and style make A Work in Progress a particularly compelling source for parent-professional partnerships. First, while the approach is clearly behavioral, Leaf and McEachin emphasize the value of an interdisciplinary approach and the importance of collaboration. Moreover, the clarity and pro-active style with which this manual is written invites its accessibility to a variety of readers who may be a part of the child’s team at one level or another (e.g., teachers, therapists, and administrators as well as behavior analysts and parents). The authors take great care to address common misconceptions about intensive behavioral intervention by offering accurate information and examples in a non-inflammatory style.

Second, while A Work in Progress includes wonderful checklists and concrete behavioral descriptions of strategies and targets, it is intended to serve as a "road map," not as a cookbook. It highlights functional analysis as a crucial aspect of intervention design. Further, while the curriculum sequence is based on developmental data, the authors remind us to leave room for flexibility. For example, some children on the spectrum will learn to read before they learn to participate in extended conversations, and this variation can be used to a child’s advantage in teaching other skills. The content of the curriculum itself may require modification to meet the needs of a particular child. However, the principles described in the manual will assist teachers and professionals to collaborate in making modifications appropriately.

A third strength of this manual is its balance. We are reminded of ways to build and maintain a good rapport with children throughout the teaching process while at the same time being consistent in our application of behavioral strategies. An emphasis on discrete trial teaching is balanced with a push towards greater naturalness in the instructional sequence as a child progresses. The importance of the learning opportunities afforded by social play with family members and peers is recognized. As a speech-language pathologist, I appreciated the authors’ acknowledgement that "language [develops] much more naturally through social interaction and play" and that "children learn from other children how to speak naturally and childlike." However, as a behavior analyst, I recognize that children with autism must learn how to learn from experiences in the natural environment, and that a carefully crafted balance of structure and naturalness (as recommended by Leaf and McEachin) is absolutely essential.

If I wanted to be picky about this manual, I’d recommend that the next edition use a "person first" style of reference. The phrase "autistic child" makes me cringe, and it’s not because it lacks political correctness. It’s because autism is just one of many traits a person may have. Autism doesn’t get credit for every unique behavior in a child’s repertoire; and, despite the autism, children on the spectrum do also have many endearing qualities. While A Work In Progress addresses the autism, it should follow its own advice by using a language style that acknowledges the whole child. If I were writing this book (and I should be so lucky!), I’d also include an alphabetized index of the skill clusters in the curriculum. That would enable more efficient access to information. But these are relatively minor issues.

The road towards maximizing the potential of a child with ASD is the bigger issue, and it’s speckled with challenges all along the way. The road map provided by A Work in Progress helps greatly to illuminate the path and to ease the journey. It is written by highly experienced teachers for teachers who want to learn, including especially parents - - arguably the most important teachers of all. It will sit on the bookshelf, next to The Me Book, Behavioral Intervention for Young Children with Autism, and Teach Me Language, to represent the contemporary behavioral approach in a non-inflammatory style that invites interdisciplinary collaboration in the interest of children with autism. It will be required reading for every one of my graduate SLP students this summer. Where was this book when I was a student?

(Mareile Koenig, Ph.D., CCC-SLP, CBA/PA is an Associate Professor of Communicative Disorders at West Chester University in West Chester, Pennsylvania, and a Certified Behavior Analyst. A lengthier version of this article, which includes more detailed information about the Work in Progress curriculum, is available from CT FEAT.)

(Sue Frost Bennett & B.C.)

In most intensive behavioral intervention programs for young children with autism spectrum disorders (ASD), basic communication and play skills are initially taught in the same environment where normally developing children learn them - at home. But as children demonstrate readiness, often sometime after turning four-years-old, they usually begin to spend increasing amounts of time in a mainstream school setting with typical peers.

Two recent lectures by ABA professionals from the River Street Autism Program, Erica Roest and Stasia Hansen, addressed various aspects of how to make the inclusion experience a successful one. A "successful" inclusion experience might be viewed as one that helps, rather than hinders, a child’s progress towards reaching his or her maximum potential for independence.

In her April 18th presentation to CT FEAT’s "Parent Resource Meeting," Ms. Roest talked about readiness criteria for preschool inclusion. (Note: many of these criteria are discussed in the book Behavioral Intervention for Young Children With Autism, Chapter 16 "Supported Inclusion.") She also spoke in great detail about related topics, including the role of the inclusion aide (or "shadow"), how to increase the child’s independence, what to look for in a classroom teacher, classroom goals, and the importance of coordinating between school and home.

In her May 28th presentation for the River Street Autism Program’s monthly lecture series, Stasia Hansen showed video clips of children in various inclusion settings. These videos demonstrated how behavioral teaching techniques are used to ease children into mainstream classrooms, according to their level of readiness.

According to Ms. Hansen, a child might begin an inclusion experience by practicing some classroom skills at school with a teacher and one or two typical peers. Then, when the data has established that the child is able to tolerate the environment for longer periods of time, he or she can advance to a regular class room setting, where the child will spend longer periods of time, with the eventual goal of attending for the entire school day. At the outset, and until such time as the child has acquired all of the skills necessary to participate successfully in the classroom, he or she must be accompanied by a highly trained aide.

In ABA programs, this aide is often referred to as a "shadow," which emphasizes the aide’s role in helping the child to achieve maximum independence. The goal, wherever possible, is for the "shadow" to ultimately fade out of the picture entirely. In order to accomplish this, the aide must be well trained in the most effective techniques for teaching the child. For example, she needs to know how to prompt the child, in the least intrusive way possible, to stay on task, pay attention to the teacher and peers, socially interact with classmates, and otherwise fully participate in the classroom.

Perhaps the most interesting part of these two lectures was the description of the classroom aide’s job. This person, who is so critical to the success of the child’s inclusion experience, must have extensive training to perform the job effectively. Optimally, the school aide should be the most highly trained member of the child’s intervention team. She should be thoroughly schooled in ABA teaching techniques, including prompting, reinforcement, task analysis, data collection, and behavior management. According to Ms. Roest, the aide "needs to know how to foster independence at every turn."

This description of the necessary qualifications for an ABA trained aide occasioned a lively discussion regarding problems parents had encountered when attempting to transition their child into the inclusion setting. These problems usually were attributed to the aide’s lack of training.

According to the parents, they frequently found that schools were accustomed to assigning their least trained, and most poorly paid, staff to act as classroom aides to children in inclusion settings. While very well intentioned, most of these "paraprofessionals" have no special training as educators, no special knowledge about autism spectrum disorders and, of greatest concern, no experience implementing ABA based teaching techniques.

As more and more children "graduate" from home-based ABA programs, and are ready to take advantage of the learning opportunities available in the inclusion setting, it becomes more urgent to focus on addressing this need for much improved training of the staff who play such a critically important role in the education of our children. ³

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Most children with Autism Spectrum Disorders (ASD) find it challenging to interact with their peers in an age-appropriate way. Successful social interactions require such complex and ever-changing skills!

With appropriate intervention, however, many children can acquire sophisticated social skills (Dalrymple, 1992). Research, and clinical experience, have demonstrated that "typical" peers can play a critically important role in teaching children with ASD to increase and improve their social communication skills (Carr & Darcy, 1990; Schreibman & Tryon, 1983; Odom, Chandler & Ostrosky, 1992).

Using peers effectively in an ABA program was the topic of the April presentation in the River Street Autism Program's monthly lecture series. Gina Drayton, Assistant Program Manager at River Street, conducted the workshop, which was entitled "The Positive Side of Peer Pressure." Ms. Drayton has a wealth of experience in this area and, judging from the videos she showed, is also a lot of fun to play with! No wonder our children--and their friends--love to participate in play dates with her!

Ms. Drayton began by listing some prerequisite skills a child should have before involving peers in teaching sessions. The child should have a low incidence of inappropriate behaviors, as well as adequate attending skills, sufficient receptive language, and some means of communicating basic needs and desires. Imitation skills are also key, so that the child can copy actions modeled by the peers. It also helps if the child knows how to play appropriately with some of the toys likely to be of interest to the peers.

Sometimes, finding these "peer teachers" can be a challenge. Siblings and relatives are often the most available peers. Neighbors and friends can be another great source, as can church and other community groups, local preschools, and classmates. Engaging in shared babysitting arrangements, or providing "after school" care for the children of working parents, may also yield lots of peer play opportunities.

Ms. Drayton mentioned various additional strategies by which parents might recruit peers. For example, parents could host "theme" parties: e.g. "We're going to have a water balloon party next week. My 'babysitter' will be in charge of it, and we moms can sit and talk on the deck." That would sound wonderful to most any parent! In addition to such structured play dates, community outings at the park, playground, and other kid gathering places may afford excellent opportunities for impromptu "peer tutorials."

The best peer teachers are those who are motivated, interested, confident, and outgoing. Ideally, they should have the ability to follow directions and be responsive to feedback and praise. Four and five-year-old girls often make fabulous peer models. Boys can also be terrific, and tend to expect less talking from their friends.

At first, it's best to invite just one peer over at a time, and then build up the group size as the child's social skills increase. When two peers come over, it's often better if they don't know each other. Otherwise, the child may get left out.

Even with model peers, play sessions can run into snags. Sometimes the peers will try to monopolize the therapist's attention. If that happens, the therapist can acknowledge them and promise to play with them for 5-10 minutes after the session, and then redirect them back to the child. If the peers dominate the activity, the adult can explain about taking turns and praise the peers whenever they give the child an opportunity to respond. Setting up turn-taking activities with spinners or similar devices can help avoid this problem too.

Sometimes peers may display anger or jealousy toward the child, since he may appear to be getting a disproportionate amount of the adult's attention. It's important to remember that the peers must have a good time in these teaching sessions. Some ways to assure this is to provide them with extra attention and positive feedback. It may also help to allow the peers to assist in the planning process for the play session, such as choosing activities, games, and locations.

If the peers inadvertently reinforce negative behaviors, the therapist can try to redirect both the child and the peers. One way is to play "freeze": when the therapist touches her nose, the peers are to stop everything and look out the window. That gives the therapist time to get the child back on track, and then enthusiastically praise the peers for being so good at "freeze!"

Sometimes the peers may be put off by some of the child's odd behaviors or mannerisms. Here, the therapist can provide simple information about the child's deficits, such as explaining that "X is really good at ___, but has trouble with ____." And the peers can be taught to give the child appropriate feedback, saying things like, "Will you stop that? It bugs me!" or "Give me my toy back!" After all, our kids need to learn how to receive, and give, this kind of feedback.

Of course, we want our children not only to have fun, but to learn things during play sessions. Some beginning goals might be: attends to materials along with peers; responds when called; approaches others; looks toward speaker; demonstrates joint-attention; engages in parallel play; joins in play; takes turns; shares materials; imitates what peer says and does, and accepts "No" from the peer. More advanced goals might include: participates in motor games (like "Simon Says" and bowling); participates in simple songs and rhymes with peers; respects others' needs (responds to "Don't do that" and other ways that peers say "No."); and asks and responds to questions.

One fun activity described by Ms. Drayton, which helps to develop many of these skills, is to have the peers play "reporter." In this game, the peers ask the child questions and write down the answers, and then the child can reciprocate. Playing games like "telephone" or "whisper" or "deliver the message" can help the child learn how to give information to peers. Other conversation skills targeted in these games include reciprocating, remaining on topic, initiating conversations, and using the phrase "I don't know." A game with a spinner pointing to various "Wh--" questions, or a bag full of interesting things, can be used in such activities.

Learning social skills can be hard work--for everyone involved. But seeing our children progress and develop friendships makes it all worth while. The sight of children playing together, independently, is precious indeed!

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(B.C.)

During the past year, the Connecticut Birth to Three System has been promoting an early intervention program for children with autism called the Individualized Support Project (ISP). This program, which was developed by Glen Dunlap and Lise Fox of the University of South Florida, focuses on reducing the serious problem behaviors (such as tantrumming) often exhibited by young children with autism.

On April 27, 1999, the Special Education Resource Center (SERC) presented a day-long lecture by Lise Fox and Pam Buschbacher, the University of South Florida educators who have been acting as consultants to the Birth to Three system in implementing the ISP model. Their presentation reviewed the history and development of the ISP model, including its major components, values, and goals. They also demonstrated some of the assessment and teaching techniques associated with the model.

According to Fox and Buschbacher, the ISP model addresses problem behaviors within a framework of "positive behavioral support," with a special emphasis on developing a family’s competence to cope with the child’s difficult behaviors. The program also seeks to develop functional communication skills and to improve the child’s comfortable participation in community environments.

Conducting a functional assessment of the child’s problem behaviors is the cornerstone in developing an ISP program. Birth to Three providers who participate in the ISP trainings learn how to conduct such assessments, which involve the use of some applied behavior analysis (ABA) based techniques for gathering and analyzing data.

Once the child’s problem behaviors are under control, the ISP model teaches positive skills using an instructional approach that is "activity based, embedded in play, and occurring in natural environments," such as home, day-care, or preschool settings. According to Lise Fox, this instructional approach has been greatly influenced by the work of Barry Prizant and Amy Wetherby (speech and language pathologists associated with the "social-pragmatic developmental" or "SP-D" teaching model).

Localities that are implementing the ISP model are referred to as "replication sites." According to Buschbacher, the "Connecticut replication model" involves six full days of training for Birth to Three staff, followed by periodic technical assistance from the consultants. During the past nine months, eight Birth to Three agencies have signed up for the training, including four "Early Connections" programs. There are currently a total of ten children receiving ISP services. Two of the Birth to Three agencies that obtained the ISP training have not yet had any clients request it. In Buschbacher’s opinion, that’s because those agencies are located in Fairfield county, which she described as a "hot bed of Discrete Trial Training (DTT)." By "Discrete Trial Training" she was referring to what is better known as intensive behavioral intervention, which usually includes significant amounts of "Discrete Trial" based teaching. The New York State Department of Health (DOH) recently issued clinical guidelines recommending intensive behavioral intervention as the most effective treatment for autism. (Editor’s note: see article regarding the DOH’s report on page 1 in this issue of the CT FEAT Newsletter)

What ARE the differences between the ISP approach to treatment and intensive behavioral intervention? And why might a parent opt for one approach over the other?

One huge difference is intensity. The ISP program calls for approximately 12 to 15 hours per week of services over a four month period. Though this is "intensive" by Birth to Three standards, where children usually receive a weekly average of only three hours of services, it is much less than that contemplated by the intensive behavioral intervention model- which typically involves 30 to 40 hours of instruction per week over a period of two to three years.

Another difference between the two approaches is long-term goals for the children. Many children receiving intensive behavioral intervention make dramatic progress and some of them even become indistinguishable from their normally developing peers. Like the ISP model, an intensive behavioral intervention program targets maladaptive behaviors. After all, as both models demonstrate, ABA provides excellent tools for managing and changing behaviors. But the intensive ABA program gives much greater emphasis to teaching adaptive behaviors, such as communication, play, and academic skills. And there is a recognition that these skills need to be acquired as quickly as possible, since there is a limited window of opportunity for the child to make maximum gains.

The ISP model, by contrast, is principally focused on the short-term goal of reducing serious problem behaviors. The lack of any sense of urgency regarding how quickly the child progresses in other domains appears to be based on the assumption that autism spectrum disorders are always life-long disabilities and that children with these disorders always will require support and services. As stated above, the ISP model favors an instructional approach associated with Barry Prizant and his colleagues. And as Ms. Fox conceded, even the "highest functioning" Prizant clients "still have autism."

Probably most informed parents (like the Fairfield county parents mentioned by Buschbacher) would prefer a more intensive intervention approach focused on achieving the child’s maximum potential. Nonetheless, there are many families that, for a variety of reasons, would find it impractical to undertake the demands of an intensive behavioral intervention program. For these families, the ISP approach may be more effective than most typical interventions (e.g. speech therapy without any behavioral training; sensory integration, play therapy, etc.), which fail to take account of the tremendous extent to which problem behaviors can interfere with learning opportunities, as well as diminish the family’s overall quality of life.

Throughout their presentation, Fox and Buschbacher made various remarks critical of "Discrete Trial" and "Lovaas" programs. They evidently consider the ISP model to be in some kind of competition for customers with the more popular intensive behavioral intervention model. I was particularly disturbed by their tendency to characterize intensive ABA practitioners as somehow cold and unfeeling and the therapy as rigid and mechanical.

The ABA consultants I have had the pleasure of working with have been among the kindest and most dedicated professionals I have ever known. With their guidance, my child has made a kind of dramatic progress that isn’t even contemplated as possible by the ISP model. Fox and Buschbacher like to think of their Individualized Support Project as "ABA with soul." But I think that "ABA Lite" would be more accurate. ³