Post on 29-Mar-2015
The CARD The CARD Treatment ProgramTreatment Program
Center for Autism and Related Disorders, Inc
Doreen Granpeesheh, Ph.D.
GPL Conference
Anaheim, California
What is ABA? What is ABA?
The CARD Treatment ModelThe CARD Treatment Model
The CARD CurriculumThe CARD Curriculum
Case Study and DataCase Study and Data
Today’s DiscussionToday’s Discussion
What is ABAWhat is ABA
ABA is based on principles of Operant Conditioning Theory
Operant Conditioning Theory:
Human Behavior is affected by events that precede it (antecedents) and events that follow it (consequences)
Application of ABA to the Application of ABA to the Treatment of AutismTreatment of AutismSymptoms Classified as:
Deficits Language Play Social Skills Theory of Mind Executive Functions
Excesses Self Stimulatory Behs Maladaptive Behs
• Tantrums
• Aggression
• Noncompliance
Skill Repertoire Building Behavior Management
The CARD Treatment ModelThe CARD Treatment Model
ABA Foundation
Serve children from 18 mo – 8 yrs
Intensive treatment
Bi-Weekly supervision
Shift from home-based 1:1 learning to peer & community based learning opportunities
0
10
20
30
40
Year1
Year2
Year3
Year4
Allocation of Hours
Home-based School-based
The CARD Treatment Model:The CARD Treatment Model: Beginning LevelBeginning LevelServices:
30-40 hours of 1:1 in-home behavioral interventionTargets:
Build a relationship with the child Increase child’s initiation with us Increase Compliance Language Training - Requests
(Mand Training) Language Training - Receptive &
expressive object & action labeling (Tact Training)
Imitation, toy play, & pretend play Self-help skills
The CARD Treatment Model:The CARD Treatment Model: Intermediate LevelIntermediate Level
Skills Taught Asking Wh Questions Conversational language Generalize language to play
& peer situations Emotion recognition Sociodramatic & imaginary
play Basic cause and effect Emphasis on generalization
& playdates begin
Services20-30 hours of 1:1 in-home intervention5-10 hours of preschool with a CARD shadow targeting social skills & generalization
The CARD Treatment Model:The CARD Treatment Model: Intermediate Advanced LevelIntermediate Advanced Level
Skills TaughtClassroom routinesFollowing complex & group
instructionsMaking inferencesObservational learningSocial skills and peer interactionPragmatic Language (e.g., introducing a topic, maintaining a conversation)Self-monitoring, Planning and Problem Solving
Services 20 hours of therapy per week:
Includes 1:1 & playdates in home & in the community 20 hours school with shadow
The CARD Treatment ModelThe CARD Treatment ModelAdvanced LevelAdvanced Level
Services
5 - 10 hours per week at home (fading out)
Gradual fading of school shadow
Skills Taught Social perspective taking Academics Continued self-
monitoring Advanced pragmatics
(e.g., detecting sarcasm) Completion of parent and
teacher training
The The CARD CARD
CurriculumCurriculum
The CARD CurriculumThe CARD Curriculum
Language PlayTheory
ofMind
Social Skills
Social Skills
ExecutiveFunction
Self Help&
Motor Skills
School Skills
The CARD Curriculum: The CARD Curriculum: Some general pointsSome general points
The child’s individual learning style is considered before particular skills are introduced
Visual Modification suggestions in each program, for visual learners
Verbal Behavior framework used in all language programsGeneralization Emphasized from very
early on At least 5
generalization ideas for each skill taught
Flexibility worksheets for each Language program to ensure generalization
The CARD CurriculumThe CARD Curriculum
Language PlayTheory
ofMind
Social Skills
Social Skills
ExecutiveFunction
Self Help&
Motor Skills
School Skills
The CARD CurriculumThe CARD Curriculum
Jody hands mom the blue crayon
3 crayons present & mom says, “give me blue”
Receptive
Jody matches blue cards3 color cards on tableMatching
Jody says, “blue”Mom asks, “What color is the sky?”
Conversatn
(Intraverbal)
Jody says, “blue”
Jody says, “blue paint”
Jody says, “blue”
Child’s Behavior
Mom says, “blue”Imitation
AntecedentFunction
Jody sees a blue carLabeling
(Tact)
Jody is ready to finger paint, but no paint
Requesting(Mand)
Language
Sample Program: Colors
The CARD CurriculumThe CARD Curriculum
Emphasis on ensuring spontaneity in Emphasis on ensuring spontaneity in language uselanguage use
Emphasis on teaching language that is Emphasis on teaching language that is functional in everyday situationsfunctional in everyday situations
Emphasis on generalizationEmphasis on generalization
Language
Overall Goals in Teaching LanguageOverall Goals in Teaching Language
The CARD CurriculumThe CARD Curriculum
Language PlayTheory
ofMind
Social Skills
Social Skills
ExecutiveFunction
Self Help&
Motor Skills
School Skills
The CARD CurriculumThe CARD Curriculum Play
Independent Play Tracking Beginning
Play
SymbolicPlay
ConstructivePlay
Imaginary Play
Sociodramatic Play
Practice Play
Games with Rules
FunctionalPretend Play
Target AreasTarget Areas
The CARD CurriculumThe CARD Curriculum Play
Features of a Comprehensive Play Skills ProgramFeatures of a Comprehensive Play Skills Program
Modeled after the development of play skills in Modeled after the development of play skills in typically developing children typically developing children
Breaks down each type of play into its own Breaks down each type of play into its own systematic and comprehensive programsystematic and comprehensive program
Sequential formatSequential format
Programs may be used individually, concurrently, Programs may be used individually, concurrently, or cumulativelyor cumulatively
The CARD CurriculumThe CARD Curriculum Play
Target mastered solitary play in Social Play program, to generalize with peers
The child generalizes the skill to social situations
Reinforce independent practice of play skill & track Independent Play to ensure spontaneity
The child rehearses the skill on their own
Our client imitates therapist/ parent in a 1:1 setting
The child observes & explores
Progression of play targets within CARD program
Typical Development of Play Skills
The CARD CurriculumThe CARD Curriculum
Pretend Imitation with Functional ObjectsPretend Imitation with Functional ObjectsPretend Receptive Commands with Functional Pretend Receptive Commands with Functional ObjectsObjectsVocalization of Pretend Play with Functional Vocalization of Pretend Play with Functional ObjectsObjectsExpressive Identification / NarrationExpressive Identification / NarrationCreation and Initiation of Pretend Play with Creation and Initiation of Pretend Play with Functional ObjectsFunctional ObjectsRequesting Pretend Play with Functional ObjectsRequesting Pretend Play with Functional Objects
Play
Sample: Functional Pretend PlaySample: Functional Pretend Play
The CARD CurriculumThe CARD Curriculum
Language PlayTheory
ofMind
Social Skills
Social Skills
ExecutiveFunction
Self Help&
Motor Skills
School Skills
The CARD CurriculumThe CARD Curriculum
Theory of mind or Social Cognition is concerned Theory of mind or Social Cognition is concerned with how children learn to conceptualize other with how children learn to conceptualize other people, growing an understanding of others’people, growing an understanding of others’
ViewpointsViewpoints ThoughtsThoughts
EmotionsEmotions IntentionsIntentions
TheoryOf
Mind
The CARD CurriculumThe CARD Curriculum TheoryOf
Mind
Social Cognitive Impairment in AutismSocial Cognitive Impairment in Autism
Inability to infer or empathize others’ desires / feelingsInability to infer or empathize others’ desires / feelingsInability to consider what others knowInability to consider what others knowInability to consider what others are thinkingInability to consider what others are thinkingInability to infer others’ beliefs / opinionsInability to infer others’ beliefs / opinionsInability to consider unintentional behaviorInability to consider unintentional behaviorInability to infer communicative intentInability to infer communicative intentInability to understand or engage in deceptionInability to understand or engage in deceptionInability to coordinate multiple social cues in a given Inability to coordinate multiple social cues in a given
social scenariosocial scenario
The CARD CurriculumThe CARD CurriculumTheory
of
Mind 9 Target Areas
Emotions
Desires
SensoryPerspectives
Knowing
PreferencesThinking
Beliefs
Intentions
Deception
The CARD CurriculumThe CARD Curriculum TheoryOf
MindSample Program: KnowingThe child learns that people know things based on the following tenets:The child learns that people know things based on the following tenets:Knowing from SeeingKnowing from Seeing
Knowing from HearingKnowing from Hearing
Knowing from SmellingKnowing from Smelling
Knowing from FeelingKnowing from Feeling
Knowing from TastingKnowing from Tasting
Multi sensory KnowingMulti sensory Knowing
Knowing from rememberingKnowing from remembering
Knowing from askingKnowing from asking
Self Knowledge (First Person)Self Knowledge (First Person)
Others’ Knowledge (Third Person)Others’ Knowledge (Third Person)
Knowing Program: Sd’s 4-6Knowing Program: Sd’s 4-6Sd 4a: “Do I know what (label/attribute/feature/etc?”)
R 4a: “Yes/No”
Sd 4b: “Why?”/ “How do I know?”/ “Why Not?”
R 4b: “Because you can/can’t see/hear/smell/feel/taste it”/”
Sd 5a: “Does 3rd person know what (label/attribute/feature/etc?”)
R 5a: “Yes/No”
Sd 5b: “Why?”/ “How does he/she know?”/ “Why Not?”
R 5b: “Because 3rd person can/can’t see/hear/smell/feel/taste it”/”
Sd 6a: “Who Knows what (label/attribute/feature/etc?)”
R 6a: Child identifies appropriate person
Sd 6b: “How does person know?”
R 6b: “Because person can see/hear/smell/feel/taste it”/”
The CARD CurriculumThe CARD Curriculum
Language PlayTheory
ofMind
Social Skills
Social Skills
ExecutiveFunction
Self Help&
Motor Skills
School Skills
The CARD CurriculumThe CARD Curriculum
Choral ActivitiesChoral Activities Community Social Community Social
BehaviorBehavior Social PlaySocial Play Following RulesFollowing Rules SharingSharing TattlingTattling
Group DiscussionsGroup Discussions Levels of FriendshipLevels of Friendship Self EsteemSelf Esteem ApologizingApologizing Cooperative WorkCooperative Work Dealing with ConflictDealing with Conflict Safety AwarenessSafety Awareness Winning and LosingWinning and Losing
Social Skills
What skills are taught?
The CARD CurriculumThe CARD Curriculum
Levels of Friendship Child learns to identify Child learns to identify
the degree of the degree of relationship he relationship he experiences with people experiences with people in his environmentin his environment
Child learns to identify Child learns to identify and rehearse behaviors and rehearse behaviors that are appropriate to that are appropriate to each relationshipeach relationship
Social Skills
Sample Program
Strangers
AcquaintancesAcquaintances
Friends
Best FriendsBest Friends
The CARD CurriculumThe CARD Curriculum
Language PlayTheory
ofMind
Social Skills
Social Skills
ExecutiveFunction
Self Help&
Motor Skills
School Skills
The CARD CurriculumThe CARD Curriculum
Self-Help elf-Help • Eating & drinking
• Toileting
• Dressing
• Bathing
• Household Chores
Self Help&
Motor SkillsComponents
Fine Motor SkillsFine Motor Skills• Arm/hand/finger strength• Drawing• Cutting• Coloring• Writing
Gross motor skillsGross motor skills• Walking & running • Ball skills• Riding a bike
The CARD CurriculumThe CARD Curriculum
Language PlayTheory
ofMind
Social Skills
Social Skills
ExecutiveFunction
Self Help&
Motor Skills
School Skills
The CARD CurriculumThe CARD Curriculum
Processes that Processes that
underlie goal underlie goal directed behaviordirected behavior
Executive Function
What is Executive Function?
The CARD CurriculumThe CARD Curriculum
Visualizing situationVisualizing situation
Identifying desired Identifying desired objectiveobjective
Determining plan to Determining plan to meet objectivemeet objective
Monitoring progress Monitoring progress to goalto goal
Executive Function
Goal Directed Behavior Involves…
The CARD CurriculumThe CARD Curriculum
Executive Function
Self-Monitoring
FlexibilityPlanning &
Problem Solving
Working Memory
Attention
Inhibition
The CARD CurriculumThe CARD Curriculum
Language PlayTheory
ofMind
Social Skills
Social Skills
ExecutiveFunction
Self Help&
Motor Skills
School Skills
The CARD CurriculumThe CARD Curriculum
Math Addition & SubtractionAddition & Subtraction Advanced CountingAdvanced Counting Money Money Telling TimeTelling Time
Reading Comprehension Book TopographyBook Topography Story ComprehensionStory Comprehension Story SummarizingStory Summarizing Text ComprehensionText Comprehension
Spelling Copying and DictationCopying and Dictation RhymingRhyming
Vocabulary Synonyms and AntonymsSynonyms and Antonyms Thematic VocabularyThematic Vocabulary
School Skills
Scope
Joey’s Story: Joey’s Story: A Case StudyA Case Study
A case study: JoeyA case study: Joey
Joey was diagnosed with Autistic Disorder in December of 1995.
CARD Treatment was initiated in February of 1996 at the age of 3 years, 6 months.
Treatment intensity ranged from 30 to 40 hours per week of 1:1 in-home and school based behavioral intervention for approximately 2 ½ years
Deficits:Profound Delays in Joint AttentionMinimal Language Inability to Interact Socially with PeersNo Purposeful Concrete or Imaginative Play
Excesses:Frequent Non-compliance Frequent Tantrum BehaviorSelf-Stimulatory Behaviors: Lining objects, “video talk”, obsessions with trains, hand flapping and gazingEcholalia
Joey’s Repertoire at Intake:
Skills: One word
expressive labels Simple imitation One step receptive
instructions Some single word
responses to social questions
At Intake…At Intake…
Services: Year OneServices: Year One
Full inclusion in general education pre-school (12 hours p/w).
Full-time CARD shadow in the classroom. 25 hours per week home based behavioral
intervention.
Intervention: Year OneIntervention: Year One
Acquiring stimulus control of pre-existing behaviorsIncreasing compliance to requestsMandsIncreasing attending behaviorReducing maladaptive behaviorsObject labels (including names, animals, places)Actions / verbsAttributes (including colors)
Play Skills
Identifying emotions
Following instructions (increasing complexity)
Functions
Gender
Categories
Academic skills (Letters and Numbers)
Plurals, tenses, pronouns
At 3 Months…At 3 Months…
At 4 Months…At 4 Months…
At 5 months…At 5 months…
At 6 Months…At 6 Months…
Year-One Progress Chart: Year-One Progress Chart: Mastered Programs Mastered Programs
0
10
20
30
40
50
1 4 7 10 13 16 19 22 25 28 31
Month
Nu
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of
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ram
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Year-One Progress Chart: Year-One Progress Chart: Mastered Sub-skills Mastered Sub-skills
0
20
40
60
80
100
120
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160
1 4 7 10 13 16 19 22 25 28 31
Month
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Year-One Progress Chart: Year-One Progress Chart: Mastered ResponsesMastered Responses
0200400600800
10001200140016001800
1 4 7 10 13 16 19 22 25 28 31Month
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Services: Year TwoServices: Year Two
Full inclusion in general education preschool 20 hours per week.
Full-time CARD shadow in the classroom 25 hours per week of home based intervention
Intervention: Year TwoIntervention: Year Two
Intermediate Social Program Getting attention of
listener before talking Initiating play and
Joining a group Regulating volume of
speech Reading the body
language of others Sharing Turn taking
Responding to Emotions
Conversational skills
Pragmatic language skills
– Adjusting conversation according to audience
(perspective taking)
– Introducing a topic
– Staying on topic
– Providing sufficient information to listener
–Ending / closing conversation
At 12 Months…At 12 Months…
At 15 Months…At 15 Months…
Year-Two Progress Chart: Year-Two Progress Chart: Mastered Programs Mastered Programs
0
10
20
30
40
50
1 4 7 10 13 16 19 22 25 28 31
Month
Nu
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f ta
ug
ht
Pro
gra
ms
Year-Two Progress Chart: Year-Two Progress Chart: Mastered Sub-skills Mastered Sub-skills
0
20
40
60
80
100
120
140
160
1 4 7 10 13 16 19 22 25 28 31
Month
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Year-Two Progress Chart: Year-Two Progress Chart: Mastered ResponsesMastered Responses
0200400600800
10001200140016001800
1 4 7 10 13 16 19 22 25 28 31Month
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Services: Year ThreeServices: Year Three
Full inclusion in general education kindergarten Fading of full time “unknown” CARD shadow 10 hours per week of home based intervention
Remaining Deficits and Remaining Deficits and Excesses Excesses
Insufficient or irrelevant descriptions and explanations Inappropriate use of questions, initiations, topic
selection and conversations Inappropriate body language Avoidance of new people and places Inflexible, routine based play Frequent crying during social activities Difficulty entering a game in progress Inappropriate reactions to joking and playful teasing Deficient friendship development and friendship
maintenance behaviors
Intervention: Year ThreeIntervention: Year Three
Identifying simple intentions
Social cause and effect Knowing Think, feel, say, do Joking, teasing, lies and
deception
Topic selection
Topic introduction
Topic maintenance
Asking questions
Making statements
Play
Social outings
At 27 Months…At 27 Months…
Year-Three Progress Chart: Year-Three Progress Chart: Mastered ProgramsMastered Programs
0
10
20
30
40
50
1 4 7 10 13 16 19 22 25 28 31
Month
Nu
mb
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f ta
ug
ht
Pro
gra
ms
Year-Three Progress Chart: Year-Three Progress Chart: Mastered Sub-skillsMastered Sub-skills
0
20
40
60
80
100
120
140
160
1 4 7 10 13 16 19 22 25 28 31
Month
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Year-Three Progress Chart: Year-Three Progress Chart: Mastered ResponsesMastered Responses
0
500
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1500
2000
1 4 7 10 13 16 19 22 25 28 31Month
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Treatment GainsTreatment Gains
0.0
2.0
4.0
6.0
8.0
10.0
Ag
e E
qu
ival
ent
Age 3.6 Age 4.1 Age 5.5 Age 7.7 Age 8.6
Vineland Adaptive Behavior Scale
Behavior Communication Daily Living Socialization
Treatment GainsTreatment Gains
0
20
40
60
80
100
120
IQ
7 mths Tx 2 yrs Tx 1 yr Post-Tx
Wechsler Intelligence Quotients
PSIQVSIQFSIQ
At Discharge…At Discharge…In January of 1999, Joey no longer presented with any of the behavioral excesses or deficits observed at intake and services were terminated.
Joey’s original diagnosis was removed by an independent clinician from an outside agency.
Currently, Joey is fully mainstreamed and thriving academically and socially in a regular education second-grade placement.
As reflected in the assessments, Joey not only made significant gains in all areas of adaptive and intellectual functioning, but continued to progress even 2 years post-treatment.
C.A.R.D.’s C.A.R.D.’s Preliminary Preliminary
Outcome DataOutcome Data
CARD Outcome StudyCARD Outcome StudyPurposePurpose
Examine the effectiveness of early Examine the effectiveness of early intensive ABAintensive ABA
Explore impact that intensity of 1Explore impact that intensity of 1stst year of year of treatment has on outcometreatment has on outcome
CARD Outcome StudyCARD Outcome Study
79 children participated79 children participated• 63 boys63 boys
• 16 girls16 girls
Average age at intake: 39.1 monthsAverage age at intake: 39.1 months Average IQ at intake: 76.8 (mild mental Average IQ at intake: 76.8 (mild mental
retardation)retardation) Length of time in tx: At least 3 yearsLength of time in tx: At least 3 years
(Children initiating program from 3/92-6/96)(Children initiating program from 3/92-6/96)
Overall Participant InformationOverall Participant Information
CARD Outcome StudyCARD Outcome Study
Of the 79 children participating:Of the 79 children participating:• 35 low intensity 35 low intensity
• 44 high intensity44 high intensity
The 2 groups were equivalent at intake in all The 2 groups were equivalent at intake in all areas examinedareas examined• AgeAge
• IQIQ
• LanguageLanguage
• Maladaptive BehaviorMaladaptive Behavior
• Adaptive BehaviorAdaptive Behavior
Participant Information:Participant Information: High & Low 1High & Low 1stst Yr. Intensity Groups Yr. Intensity Groups
CARD Outcome StudyCARD Outcome Study
Intervention: Hi Intensity Group: Received 26 or more
hours of CARD services (including school aide) per week.
Low Intensity Group: Received 25 or fewer hours of CARD services (including school aide) per week.
CARD Outcome StudyCARD Outcome Study
61%
20%
Mean Client IQ Pre- and Post-Treatment
70
75
80
85
90
95
100
1 2
IQ S
tan
dar
d S
core
High Intensity
Low Intensity
Pre-Treatment Post Treatment
CARD Outcome StudyCARD Outcome Study
61%
20%
Mean Adaptive Functioning Pre- and Post-Treatment
60
65
70
75
80
85
90
95
100
1 2
Vin
elan
d S
tan
dar
d S
core
High Intensity
Low Intensity
Pre-Treatment Post Treatment
CARD Outcome StudyCARD Outcome Study
0
10
20
30
40
50
60
70
Per
cen
t
1 2
Normal IQ, Adaptive Fxn and Placement
25 hrs or less / wk 26+ hours / wk
61%
20%
CARD Outcome StudyCARD Outcome StudyFactors Associated with Positive Factors Associated with Positive
OutcomeOutcomeIntensity: 26+ Hours per week Intervention
Age at Intake: Treatment initiated prior to age 4
Parent Participation: Parents conduct therapy, attend clinics, read log book
Exposure to Typical Peers: When school is introduced, Regular Education is bestConcurrent Medical Management of Symptoms: Dietary changes & use of medsVerbal Imitation within the first 6 months of treatment
Dr. Doreen Granpeesheh
GPL Conference
CARD
QuestionsQuestions
Visual ModificationsVisual Modifications
Designed based on the childSome examples Picture Exchange Communication System
(PECS) for children with difficulty communicating vocally
Stimulus modifications for children with difficulty with auditory comprehension
Response modifications for children with difficulty with vocal output