Slide 1

Rose Iovannone, Ph.D., BCBA-D University of South Florida iovannone@fmhi.usf.edu 813-974-1696 Slide 2 Objectives Participants will: Describe the standards for establishing an intervention as evidence-based Use guiding questions to determine the level of evidence held by various interventions Describe the features of several interventions with established efficacy for young students and explain how to implement them in their environments Slide 3 Agenda What is evidence? Examples of strategies with evidence Resources Slide 4 If youve seen one child with Aspergers Syndrome or autism, you have seen one child with Aspergers Syndrome or autism. Brenda Smith Myles November 14, 2000 Slide 5 Slide 6 Evidenced-Based Practice An instructional strategy that: Has a base of high quality research over a range of different students, in a range of places, and over a range of behavior Has been shown to result in measurable educational, social, or behavioral benefit Slide 7 Identifying Evidence-Based Interventions Reliance on sources such as expert opinion is contrary to evidence-based practice approach because such alternatives have many sources of potential bias. Gambrell, 2003 (page 13) Slide 8 Identifying Interventions Internet as a source is overwhelming: Example: term autism cure Google search 2 time points (Feb. 2005-Feb. 2006) Change in number of web pages528,000 to 5,290,000 (Long, 2006) Many not evaluated nor provide reliable information about their claims (or outcomes) Training programs (for practitioners) do not consistently disseminate evidence-based practices Slide 9 Identifying Interventions No single research method can answer all questions Experimental: Manipulating variables systematically quantitative Descriptive: Description of naturally occurring relations between 2 or more variablesqualitative Experimental provides the answer about an interventions impact on behaviors Descriptive provides directions for research; does not demonstrate causal relationships Slide 10 Two Methods of Establishing Evidence Threshold (restrictive) Number of randomized clinical trials (standard = 2) Hierarchy of Evidence (more inclusive) Continuum (4-5 points) of evidence Example: Well established to no supporting evidence Evaluating evidence Randomized control trials = gold standard Well designed quasi-experimental studies = acceptable but weak Single-participantnot clear Slide 11 Identifying Interventions Currently, there is no reliable database for validated autism interventions Alternativeconstruct interventions that contain principles of behaviorFormative E.g., antecedent control, positive reinforcement, shaping, fading Slide 12 Implementing the Intervention Match to sample Training of intervention agents Characteristics of students Environmental context Training and fidelity issues Slide 13 Evaluating the Intervention Measuring progress should occur frequently and systematically Two questions: Is the behavior changing? At what rate is behavior changing? Slide 14 Guidelines for Consumers (Detrich, 2008) Decisions about interventions should be based on the best available experimental evidence In the absence of clear evidence-based information, interventions should be developed that use strategies from the established principles of behavior When modifying an intervention, base it on the established principles of behavior Select interventions that were tested situations similar to those of the specific student Direct training should be provided to practitioners Fidelity measures should be collected regularly Systematic evaluation of progress should be conducted Slide 15 Slide 16 Guides National Research Council (2001) National Standards Report (2009) Iovannone et al., (2008, 2003) Slide 17 National Research Council Practices recommended: Curriculum focus on social interaction, play and communication Specialized servicesspeech/language & occupational therapy Family involvement Consistent and ongoing communication between team members Capacity to address behavioral challenges Specialized and ongoing training and support to staff Slide 18 http://www.nationalautismcenter.org/ab out/national.php Slide 19 NSP Evidence-Based Interventions 2009 Report is the first. Future reports will expand focus of criteria for inclusion -Looked only at educational and behavioral interventions (excluded biomedical with exception of curative diets) -Looked at only two classes of research design (group and single-subject) -Limited scope to strict diagnostic criteria Slide 20 NSP Strength of evidence Strength of Evidence Classification System used by National Standards Project Established Emerging Unestablished Ineffective/Harmful Slide 21 Slide 22 Established interventions 1. Antecedent Package 2. Behavioral Package 3. Comprehensive Behavioral Treatment for Young Children 4. Joint Attention Intervention Slide 23 Established interventions 5. Modeling 6. Naturalistic Teaching Strategies 7. Peer Training package 8. Pivotal Response Treatment Slide 24 Established interventions 9. Schedules 10. Self-management 11. Story-based Intervention Package Slide 25 Unestablished interventions Academic Interventions Auditory Integration Training Facilitated Communication Gluten-and-Casein-Free Diet Sensory Integrative Package Slide 26 Effective Educational Strategies (Dunlap, Iovannone, & Kincaid, 2008; Iovannone, Dunlap, Huber, & Kincaid, 2003 ) Individualized Supports and Services Systematic Instruction Comprehensible/Structured Learning Environments Specific Curriculum Content Functional Approach to Problem Behavior Active Family Involvement Slide 27 Evaluative Questions for Interventions Will the intervention impair or detract? cause frustration or regression? What happens if method proves ineffective? Is method balanced with other components? Is the intervention developmentally appropriate? Slide 28 Evaluative Questions for Interventions Has the intervention been validated scientifically? How will the intervention be integrated into the individuals current program? Have appropriate outcomes and assessment methods been identified? Does it lead to increased independence? What is impact on quality of life? Slide 29 Activity Matrices Prompting Hierarchy Data FUNN Positive Behavior Support Slide 30 Characteristics of Critical Skills Broad classes of behaviors Variety of contexts Required to complete part or all of activity Not THE activity Not sweeping, taking out trash, washing dishes Insteadcommunicating need for materials, using both hands together to complete task, initiate social interactions Repeated use throughout all daily activities and routines Activity-based goals may limit opportunities for student to practice skill throughout day (e.g., sweeping) Examplesexpressing concerns, bilateral coordination, response to social interactions Slide 31 Identifying What to Teach: Critical Skills Broad classes of behaviors Variety of contexts Required to complete part or all of activity Not THE activity Not sweeping, taking out trash, washing dishes Insteadcommunicating need for materials, using both hands together to complete task, initiate social interactions Repeated use throughout all daily activities and routines Slide 32 32 Use an Activity Matrix to: Plan for specialized instruction Assess individual needs in classroom setting Plan when data collection will occur Plan activities and materials necessary for incidental teaching or embedded instruction Slide 33 33 Activity-Based Intervention Matrix adapted from Grisham-Brown and Hemmeter, 1998 Slide 34 Slide 35 CHILDREN ACTIVITIES Child 1Child 2Child 3 Free Play -App. Play (intro new toys and independent play with bins) -Matching (pic to pic) -Ask for preferred toy (PECS) -App. Play (new play activities) -Ask for preferred toy or material -Point to pic in book (rec. ID) -Independent play -Asking/Answering questions -Sharing and trading (new) Clean-up/transition -Simple dir (stand-up, give me) -Put toys away -Move chair to circle Independent toileting (initiating) -Simple dir (stand-up)-Follow multi-step directions Circle -Simple dir (clap hands, stand- up) -Imitation (gross motor, oral motor) -Simple dir (stomp feet, sit down, stand up) -Imitation (gross/fine motor) -Asking questions -Advanced imitation Outside -Imitation (gross motor) -App. Play (intro new activity, initiate new activity) -App. Play (new play activities) -Independent play (new activities) Snack -Request desired food items (PECS) -Proximity to peers -Request snack items (PECS) -Proximity to peers -Asking questions (What, Who, Where) Structured Activity -Proximity to peers -Request materials (PECS) -Matching -Request materials (PECS) -Matching (colors) -Matching pic and obj (gen) -Peer imitation -Pronoun/gen (my, your, his,her) -Advanced conversations Classroom Activity Matrix Slide 36 Time/ Routines Skills Play with sister (Interactive play) Ask for items without being told (initiate communicative requests) Paying attention to what mom attends to (joint attention) Play with toys (Imitate motor movements) Make choices between 2 Imitate sounds Snack time 3:00-3:15 Essential item missing or in closed container; child needs to request Point to favorite item look; give when child follows point Choose sequence of eating Imitate childs vocalizations Outside time 4:00-4:30 Roll ball back & forth to sister Time delay push child on swing & stop; wait for more Pause before responding in established routine praise for anticipation Car/doll demonstrate functional act for imitation Choose activity Imitate childs actions and make minor change Bathing 7:00-7:30 Float toy back & forth to sister Essential item in sight but out of reach Splash hand in water look Toy chosen by child demonstrate functional act Choose toy to take to bath Slide 37 Slide 38 38 Activity-Based Intervention Matrix A DAILY SCHEDULE OF ACTIVITIES IEP Objective #1:Making Choices (Level E, P) Center TimeBlock center or housekeeping? Classroom ChoresWater plants or feed fish? Snack/Cooking ActivityPudding or milkshakes? Small Group-ArtWhich art materials to use? Going to Park with ParentsSlide or swing? # Opportunities: 5 adapted from Grisham-Brown and Hemmeter, 1998 Slide 39 39 Activity-Based Intervention Matrix B HOME - SCHEDULEIEP Objective #1:Making Choices (Level E, P) BreakfastBlock center or housekeeping? Laundry w MomWater plants or feed fish? Lunchtime PreparationPudding or milkshakes? Reading TimeWhich art materials to use? Playing with my BrotherSlide or swing? # Opportunities: 5 adapted from Grisham-Brown and Hemmeter, 1998 Slide 40 40 Activity-Based Intervention Matrix C DAILY SCHEDULE OF ACTIVITIES IEP Objective #2:Reach and Grasp (Level M, E) Center TimeBuild tower w/ blocks Classroom ChoresReach for/grasp attendance slip place on desk in office Snack/Cooking ActivityReach for/grasp cooking utensils Small Group-ArtReach for/grasp built-up paintbrush handle Going to Park with ParentsReach/grasp to hold onto swing/side of slide # Opportunities: 5 adapted from Grisham-Brown and Hemmeter, 1998 Slide 41 41 Activity-Based Intervention Matrix D HOME SCHEDULEIEP Objective #2:Reach and Grasp (Level M, E) BreakfastBuild tower w/ blocks Laundry w MomReach for/grasp attendance slip place on desk in office Holiday Baking w MomReach for/grasp cooking utensils Gluing Stuff w MomReach for/grasp built-up paintbrush handle Play Games with my Brother Reach/grasp to hold onto swing/side of slide # Opportunities: 5 adapted from Grisham-Brown and Hemmeter, 1998 Slide 42 42 Activity-Based Intervention Matrix E DAILY SCHEDULE OF ACTIVITIES IEP Objective #3: Initiate Social Interaction (Level P, I) Center TimeGreet other children vocalize or eye contact` Classroom ChoresInitiate contact with office personnel Snack/Cooking Activity Eye contact w/ peers their turn to stir Small Group-ArtInitiate interaction w/ adult ask for assistance Going to Park with Parents Eye contact/vocalize to let know what she wants to be pushed # Opportunities: 5 adapted from Grisham-Brown and Hemmeter, 1998 Slide 43 43 Activity-Based Intervention Matrix F DAILY SCHEDULE OF ACTIVITIES IEP Objective #4: Cause/Effect (Use of Switch) (Level E,P or I) Classroom ChoresUse switch to turn on toy (dump truck @ blocks center building site) Snack/Cooking ActivitySwitch to activate blender etc Small Group-Art Going to Park with ParentsSwitch to turn on music box Classroom Chores # Opportunities: 3 adapted from Grisham-Brown and Hemmeter, 1998 Slide 44 Slide 45 Slide 46 Slide 47 Slide 48 Slide 49 Activity Matrix Time/ Routines Skills Socially interact with peer Ask for items without being told (initiate communicative requests) Paying attention to what adult attends to (joint attention) Play with toys (Imitate motor movements) Make choices between 2 Ask for help Circle time 9:00-9:20 Have greeter role: Hand out materials and greet each peer Point to favorite item look; give when child follows point Choose order of greting Recess 10:20-10:45 Roll ball back and forth to one peer Withhold favorite toy item (ball); provide opportunity for student to request the ball Car/doll demonstrate functional act for imitation Choose peer for playing Reading 1:00 1:45 Essential item in sight but out of reach Choose book to read for group read Slide 50 Prompting Hierarchy Natural Cue Gesture Verbal Visual/Picture Model Physical (partial, full) Full Physical MOST TO LEAST LEAST TO MOST Slide 51 Making Data FUMM (FACETS) Functional Include as part of activity Useful Child responses accomplish routine outcome Meaningful Varied formats to show progress Measurable Obvious, quick, countable Slide 52 Making Data-Collection Teacher and Family Friendly Locate close to area where intervention most likely to occur E.g., Clipboard, wall near teaching location, tape recorder on kitchen countersnack routines; tape data form to mirror in bathroom for bathing/toileting routines; index card in diaper bag Data collection should serve as visual prompt for data to be collected E.g., add symbols/pictures to illustrate key steps or targets Easy and quick to use E.g., Fill-in-the-blank, checklist, circle-response format Space for comments/notes Slide 53 Amys Difficulties Week of: ___ MondayTuesdayWednesdayThursdayFriday Arrival0 1 2 3 Circle0 1 2 3 Nap0 1 2 3 Clean-up0 1 2 3 Other: Bus ride 0 1 2 3 Average Score 3.02.21.4.8 0=no problems, 1 = whining, resisting; 2= screaming, falling on floor; 3=screaming, hitting, other aggression Slide 54 MondayTuesdayWednesdayThursdayFridaySaturday 444444 333333 222222 111111 Bens Playtime 4=Laughing, stayed 3=Cooperated, stayed briefly 2=Fussed, took several turns1= Cried, refused to play Slide 55 Always Never Always Never Always Never Kicking Engaged Call-outs 3-7 3-83-9 3-10 3-13 3-143-153-163-17 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 Key: Engaged5=completed tasks in both routines, no prompts; 3=completes task with 1-3 prompts; 1=did not complete tasks, needed >5 prompts or removal. Call-outs5=10 or more; 3=4-6; 1=0. Kicking5=>5 kicks in group work time; 3=3 kicks; 1=0 kicks Slide 56 Dustys Signs During Routines MEAL TIME Eat Drink More Hot Cookie Fork Cracker Hungry Thirsty All done Spoon DIAPER CHANGE Diaper Clean Throw away All done Body parts Peek-a-boo Dirty Stinky Stand up Lay down Wait Slide 57 Jimmys Problem Behavior During Feeding 123 Monday No problemsSome problems Lots of problems Tuesday No problemsSome problems Lots of problems Wednesday No problemsSome problems Lots of problems Thursday No problemsSome problems Lots of problems Friday No problemsSome problems Lots of problems Slide 58 Jimmys Problem Behavior During Feeding Slide 59 Slide 60 Got ABA Principles? Slide 61 Applied Behavior Analysis (ABA) ABA is not a specific program, procedure, or a technique; it involves methods and principles that are applied in diverse ways. Dunlap, 1999 Slide 62 Intervention Approaches Using ABA Principles Discrete Trial PECS Verbal Behavior Incidental Teaching Time Delay Pivotal Response Training Positive Behavior Support Functional Behavior Assessment Slide 63 Incidental Teaching Procedure Environment arranged to promote teaching episodes Child initiates episode by expressing interest Adult follows child lead and establishes joint attention Adult models behavior, then looks expectantly at child Slide 64 Incidental Teaching Procedure (continued) If child does not respond, adult provides mand (request) If child does not respond to mand, adult provides physical prompt Adult provides natural reinforcement Slide 65 Example: Incidental Teaching Procedure Environment arranged to promote teaching episodes Arrange water table with variety of preferred objects Child initiates episode by expressing interest Child moves to table or gazes at table Adult follows child lead and establishes joint attention Playing in water is fun. Look at the boats! Adult models behavior, then looks expectantly at child I found a boat! Can you find a boat? Slide 66 Example: Incidental Teaching Procedure If child does not respond, adult provides mand (request) Pick up a boat. If child does not respond to mand, adult provides physical prompt Ill help you, boat! Adult provides natural reinforcement Its fun to find the boats! Slide 67 How do you Know When to Follow Childs Lead? Look for: Gaze shift/look at item (tracking) Reach Grab Verbalization (can be a whine or a cry toward item) Label Request (in various forms) Slide 68 Important Part: Reinforcers! New skills: Select powerful reinforcer(s) Reinforce each time! Reinforce IMMEDIATELY after desired behavior Change reinforcers (avoid satiation) Pair with verbal praise Be specific Slide 69 What is Prevent-Teach-Reinforce (PTR)? Research project funded by U.S. Department of Education University of South Florida & University of Colorado, Denver Purpose: Investigate effectiveness of PTR process vs. business as usual Comparing treatment and wait-list compariosn groups Making process prescriptive, yet simple Intervention Package ONE Prevent; ONE Teach; ONE Reinforce Based on ABA principles and individual Positive Behavior Support Slide 70 Slide 71 PTR Model Based on principles of behavior and values of positive behavior support Five step process Teaming Setting Goals Functional Behavior Assessment Interventions Training, coaching, and fidelity measurements Evaluation and monitoring Slide 72 Slide 73 Step 1: Team Building Team Development Include relevant stakeholders Team Collaborationenhancers and inhibitors Tools Work style survey Teacher and Teacher Assistant Teaming survey Slide 74 Step 2: Goal Setting Purpose: Identify behaviors of greatest concern to the team and possible replacement behaviors (teach) Prioritize and operationalize behaviors Develop teacher friendly baseline data collection system Targeted Areas: Problem behaviors Social skills Academic behaviors Slide 75 Case Study- Mike: Behavior Rating Scale Behavior Screaming9+ times 7-8 times 5-6 times 3-4 times 0-2 times 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 Hitting8+ times 6-7 times 4-5 times 2-3 times 0-1 times 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 Expressing Frustration 40%+ 30-40% 20-30% 10-20% 0-10% 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 Transition to Non-preferred Whimper or squeal Louder than indoor voice Outdoor play voice Louder than outdoor play Ear penetrating 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 5432154321 Date Slide 76 Step 3: PTR Assessment (FBA) PTR Assessment (FBA) Each team member independently answers a series of questions related to: Observed antecedents/triggers of problem behaviors Functions of the problem behaviors Consequences ordinarily associated with the problem behaviors PTR facilitator summarizes input and develops draft hypothesis Team reaches consensus Slide 77 Step 3: Case Study Mike Hypotheses When.he willAs a result Mike is asked to complete non- preferred tasks (Reading, Math), stop preferred activity or transition to non-preferred activity, fix an error, or when teacher is attending to other students scream and hitMike is able to gain attention and delay the transition/activity Mike is asked to complete non- preferred task (Reading, Math), stop preferred activity or transition to non-preferred activity, fix an error, or when teacher attending to other students express his frustrations appropriately complete the assigned task Mike is able to delay the transition/activity Mike is able to gain attention Inappropriat e Appropriate Slide 78 Step 4: Behavior Intervention Plan Team selects interventions from each component (P-T-R) Team selects interventions from each component (P-T-R) Detailed behavior plan developed Consultant provides training and on-site assistance with plan implementation Implementation fidelity evaluated Slide 79 Prevent Strategies Specific Strategy steps Environmental Support A wait card will be placed on Mikes desk to assist him in remembering to wait his turn. 1. Prior to group work, tell Mike, Remember, when it is someone elses turn, you sit quietly and wait, while pointing to his card. 2. If Mike calls out, point to his visual to remind him what to do. 3. Use a verbal prompt if the point prompt does not work. Step 4: Case Study Mikes BIP Slide 80 Prevent Strategies Specific Strategy steps Environmental Support Mikes visual schedule will be modified to detail the number of and type of activities he is to complete during non-preferred activities. For example, if math involves listening to a lesson, doing a hands-on activity, and completing a worksheet, his visual schedule will list each activity under math using either a picture of the type of activity or using numbers that correspond to a number on the worksheet. 1. Prior to the start of the activity, Mike should review the visual schedule. 2. As Mike completes an activity, he should X off the activity. Mikes Intervention Plan Slide 81 Prevent Strategies Specific Strategy steps Curricular Modification Mike will be given an easy, independent activity, such as a worksheet, to complete upon transitioning to a non-preferred activity or an activity that requires him to wait, such as group activities 81 Slide 82 Teach Strategies Specific Strategy Steps Replacement Behavior Mike will be taught to use his voice output device to express his need to calm down. Steps: 1. Mikes device will be programmed to say I need to calm down. 2. Prior to transitioning to a non-preferred activity or at the end of a preferred activity, say If you start to get mad, you can choose to calm down. 3. As soon as Mike starts to get upset, prompt him to use his device (hierarchyhand-over-hand, gesture, verbal). 4. Once Mike communicates I need to calm down, present him with the choice board of calming strategies and ask him, What do you want? 5. As soon as he is calm, praise him (e.g., You made a good choice.. 6. Allow Mike to engage in his choice until he is calm for 1- minute. 7. If Mike does not want to leave his choice, then start becoming animated with students in the non-preferred activity. Slide 83 Teach Strategies Specific Strategy Steps Self- Management Mike will be taught to independently use his calming strategies. 1. A tracking sheet with smiley faces and sad faces will be given to Mike at the start of each day. 2. Role-play with Mike about when he needs to make the choice to calm down. 3. Practice completing the tracking sheet. 4. Set and review the daily goal for using the calming strategies. 5. Prompt Mike to complete the tracking sheet if needed Slide 84 Reinforce Strategies Specific Strategy Steps Replacement Behavior Anytime Mike says I need to calm down, his choice board should be given. 1. Praise Mike for communicating (thank you for telling me what you need.) 2. Provide his choice board. 3. Allow him to calm for 1 minute 4. Praise him as soon as he is quiet 5. Praise him for returning to the group Self- Management Anytime Mike scores his behavior, attention should be given. 1. When Mike marks his tracking sheet, praise him for doing so. 2. At the end of the day, review the sheet with Mike. 3. Talk about the sad faces. 4. Provide his reward if his goal is met. WaitingMike will earn a skittle paired with attention if he waits. This will be faded to an intermittent schedule. Slide 85 Reinforce Strategies Specific Strategy Steps TransitionMike will earn stars during Reading Centers if he transitions and completes his work without screaming. 1. A social story will be reviewed prior to Reading Centers to remind Mike that he can earn a star if he comes to centers and works. 2. At the end of each reading center, an adult will review Mikes behavior with him and ask him if he earned his stars. 3. Provide his stars if earned. 4. During the teachers group, Mike can earn 2 stars: 1 for transitioning to the group and 1 for working during group. 5. Allow Mike to participate in his chosen activity if he earned his stars. Slide 86 Step 5: Evaluation Is it working? Daily ratings of behavior Continuous progress monitoring BRS Other data collection forms Is it being implemented consistently and accurately? Fidelity ratings Do we need more data? Does the plan need to be modified or expanded? Plan for generalization and maintenance Slide 87 Step 5: Mike Evaluation Slide 88 Step 5: Evaluation Slide 89 Slide 90 Slide 91 Manual will be published by Brookes (November 2009) Two journal articles in press (both provided) Journal of Positive Behavior InterventionsCase study Journal of Emotional Behavioral DisordersPreliminary outcomes Next steps: Facilitating schools to scale up Training key school staff and team members to do process News and Noteworthy Slide 92 Slide 93 Slide 94 http://depts.washington.edu/pdacent/ Slide 95 Slide 96 Slide 97 http://card-usf.fmhi.usf.edu/ Slide 98 Slide 99 http://www.albany.edu/psy/autism/cardfactsheets.html Slide 100 http://www.mcie.org/ Slide 101 http://www.ocali.org/ Slide 102 http://ies.ed.gov/ncee/wwc/ Slide 103 Slide 104 Slide 105 For Copies of PowerPoint: E-mail: iovannone@fmhi.usf.eduiovannone@fmhi.usf.edu Slide 106 Questions????