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Archive for the ‘autism’ Category

a guest blog post by Scott Badesch, ASF Board Member, Former President, Autism Society of America

I am a proud member of the board of directors of the Autism Science Foundation.

I recently retired as the President/CEO of the Autism Society of America.  I have four adult children, one who is autistic, and a great son-in-law.   I also am a grandfather to the most precious grandson in the world.  My wife and I have been married for 36 years and before this crisis and even now living through this crisis, we know we are blessed in that we have each other, friends and family.  We have started a daily FaceTime call with our kids and grandson and we are actually talking with each other and not texting on our cell phones. 

Like everyone, I am scared and anxious. I see my retirement funds going down drastically and my planning for retirement never ever considered the impact of a global crisis.  I wonder if i will be able to leave retirement if I need to and find work when this is over. I also fear for the future of each of my adult children as well as my grandson. But I also see good coming ahead.

I hope we will get through this crisis with a better understanding of how we all are in this together.  And I think people are seeing that.  It’s what happens during a crisis. In crisis, people often put aside their hate and stereotype thoughts and just give a hand to a person in need.

Let’s admit it.  Before the crisis, we were not really good when it comes to valuing every person, especially individuals who are impacted by autism.  But today, it is different.  Globally, we are all dealing with the same thing. We now are assured that what happens anywhere else impacts us.  We need to start thinking that we are not defined by our geographic boundaries but the boundaries of what we call earth.  Our skin color, nationality, religion, disability, sexual orientation or sexual preference can no longer be the definition of who we are.  Rather we are all similar human beings.

I believe that as difficult as it is right now, we will come out of this crisis much better and I also strongly believe that people impacted by autism will be better off when we exit this crisis.   Today, we are all anxious, concerned about how we can find food for our meals, coping with being out of work, not knowing if work will be there for us and constrained by significant financial issues.  Heck, we are worried about finding toilet paper!   To so many autistic adults, what we are experiencing is unfortunately the life too many impacted by autism live each day. But I am optimistic about our future when it comes to helping autistic individuals in need. As a close friend said to me the other day, “I always have been blessed to have things come easy to me.  Now, they don’t. I am worried that I won’t have food to feed my family, dealing with high anxiety by everyone, and worried about my future unknown.”  He then said that he never has understood the difficulties that so many in need face, but now he has a sense of it and has to be responsive to it in the future. I think my good friend and millions of others will hopefully learn from all they are dealing with now and be more responsive to helping others in need when they return to whatever is defined as the “new normal.”

Our challenge is big but maybe it can start if everyone can get a mulligan and we all stop our hate and begin to listen to each other so we will come out of this as better human beings.  If we stop the denial of opportunities to too many, we can live in a global world where all are equal and included.  When someone has billions of dollars and there is a child who has to wake up in a car each morning; when an autistic young woman is denied access to a job because of an employer not understanding her skills and value; when an autistic person has to wait in some states eight or more years for basic services……maybe we really deserve this recheck.

We can’t fix the problems with the old solutions that if we are honest are temporary and often don’t work.  We must be bold and give all we deal with a rethink. Let’s rethink how we can appreciate our differences and need to be there for each other. Let’s put everything on the table.  Let’s realize that a person sleeping in a car doesn’t benefit from a bail out of the airline industry but we still have to allow commerce to start again. We owe the kid in the car a life of opportunity which can never occur if that kid uses the public swimming pool locker room as his family bathroom. We owe every person with autism the commitment that we will be there for him or her today and not promise we might be there tomorrow.  We owe every person impacted with autism every access to life’s opportunities.  And we owe our society’s help to every person impacted by autism who can benefit from such help.

What we learn from this will be what we can be after this is all over. I am optimistic that maybe, just maybe, we are in for a massive recheck of who we are and we will come out of this so much better. 

As I said, I am optimistic about our future!  On a personal basis, I know as a father of an adult son impacted by autism, that he has been denied opportunity because of the ignorance of others who decide simply because he is autistic he is not entitled to life’s opportunities. Prior to this crisis, I believed change came slowly and incremental advances were what might occur.  Today, I think we can make large changes and advance the wellbeing of everyone.   

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a guest blog post by Gary Mayerson, Founder, Mayerson & Associates

The COVID-19 crisis transcends the obvious health and existential threat, with millions of school-aged children across the country home from school indefinitely as we watch an ongoing and as yet unresolved wrestling match involving Congress, the U.S. Department of Education, state administrative agencies, (e.g. the New York State Education Department), and local educational agencies (e.g. the New York City Department of Education). 

Families are calling with the following kinds of questions.  For example, can unmet IEP mandates give rise to a claim for compensatory education?  Can the local school district provide my child with remote learning opportunities?  If I am thinking about securing private services for my child, can the school district be made to pay for those services?  Before I secure private services for my child, do I need to send my school district a “ten day notice” preserving my right to seek reimbursement for the cost of those services?  Am I permitted to contract with service providers to come into my home if they are willing to do so?  Since I am now spending the entire “school day” with my child, can I get  (or secure funding for) “parent training” hours?  Do I have any insurance coverage that may help to fund any of the supports my child may need?  Should I request that my school district’s IEP team reconvene as a telephonic meeting?

The U.S. Department of Education has published and circulated March, 2020 Questions and Answers that, unfortunately, do not definitively answer these kinds of issues. The crisis has put us all into largely uncharted territory.  However, the Department of Education’s Q and A does suggest that if you are living in a school district that is offering remote learning opportunities, your family may have greater options and rights going forward than families living in school districts that are not offering such opportunities.

Each family’s circumstances will be unique.  For that reason, families should consult with their attorney before contracting for private services or taking other related steps. In the meantime, I am calling on all parents to help stop an ignoble legislative initiative and threat that, if allowed to pass, could easily destroy or at least significantly dilute our children’s entitlements under the federal IDEA statute and related state regulations.

Lamar Alexander’s (R-TN) Shameful Effort To Nullify Or Dilute IDEA Entitlements

 As part of Congress’ response to the COVID-19 outbreak, the bill introduced earlier this week in the Senate — the Coronavirus Aid, Relief, and Economic Security Act  (to provide an infusion of cash to key industries, support for health care providers/health care systems and more) also includes a provision directingthe Secretary of Education [Betsy DeVos] to report back to Congress within 30 days on any “waivers” needed under the IDEA and the Rehabilitation Act of 1973 (Section 504).The bill also gives the Secretary broad waiver authority over the Higher Education Act (HEA), the Elementary and Secondary Education Act (ESEA) and Carl D. Perkins education laws.

To be sure, these “waiver” provisions jeopardize every child’s rights to Child Find, a free appropriate public education (FAPE), Individualized Education Program (IEP), all procedural safeguards, re-evaluations, related services and accommodations.

As if COVID-19 was not already a serious crisis for families whose children are now not attending a school-based program, this legislative initiative threatens to eliminate every child’s fundamental right to Child Find, a free appropriate public education (FAPE), Individualized Education Program (IEP), all procedural safeguards, re-evaluations, related services and accommodations, and more.  To say the least, Congress should not be giving the nation a trillion dollar stimulus package while at the same time sweeping America’s disabled children under the rug.  It is time for our entire community to sound the alarm. 

My office is following this development closely and undertaking efforts to challenge this shameful proposal.  We urge all families to join us by reaching out to their Senator/Representative today (via email).

Find Your Senators here: https://www.senate.gov/general/contact_information/senators_cfm.cfm

U.S. Senate: Senators of the 116th Congress http://www.senate.gov _Senators of the 116th Congress 

Find your Representative here https://www.house.gov/representatives/find-your-representative

A sample email follows: 

Dear Senator/Representative:
While the COVID-19 outbreak has placed a tremendous and unprecedented strain on schools and districts, it is imperative that we work together to find solutions that allow children to receive equitable access to an education and the services that support them without undoing all of their civil and educational rights. I am writing as a concerned (parent/teacher/child advocate) to urge you to reject any proposal that would provide waiver authority to the Secretary of Education regarding the Individuals with Disabilities Education Act (IDEA). More than 7 million children and their families rely on the federal IDEA statute to receive special education supports and services. 

I hope you will help schools by providing states with additional funding that can be used to provide teachers and school leaders and families with the tools they need to connect to teach and support students. Schools can also be supported with funding to provide an extended school year to students and other compensatory services. 

COVID-19 does not discriminate on the basis of party affiliation. The IDEA statute came into being as a bipartisan effort that families across the nation have relied upon for decades. Please continue to support students with disabilities and their families who rely upon the IDEA so that they can access appropriate and effective educational programs. Please do not support any legislative initiative that would give any one individual the power to undo and eviscerate IDEA.

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a guest blog post by Erin Lopes, CRNP, MPH, Psychiatric Consult Liaison Service

Information about COVID-19 is evolving on a daily basis. We do know is that COVID-19 is a novel pathogen and therefore we expect that people with autism are equally at risk for infection with COVID-19 as anyone else. If we apply the epidemiologic trends from the general population, there may be a greater likelihood that adults with autism (age >18 years) rather than children will be hospitalized.

1) If Parents/caregivers are worried their child or loved one with autism may have COVID-19, they can avoid going to the emergency department (ED) or urgent care clinic for a test. Parents/caregivers can call their child’s pediatrician or primary care provider and inquire about drive up COVID-19 test sites. Drive-up test sites the advantage of allowing patients with autism to avoid coming into the ED or doctor’s office. The COVID-19 test involves obtaining a nasal/pharyngeal swab that can typically be collected in less
than a minute. Although the test is quick people can experience mild discomfort while the swab sample is being obtained in the nares. Families or caregivers may need to offer reassurance and support to their loved ones with autism while the test is being administered.

2) If a child or family member with autism presents with more urgent symptoms and needs to be seen in the emergency department it’s important for parents/caregivers to assist ED staff to understand:
– The ED may be understaffed, give a clear and concise history of your child or family member’s current symptoms to help staff provide care efficientl
– Be clear about when the symptoms first started
– Explain how your child or family member with autism communicates, particularly for patients with autism who cannot verbalize pain or discomfort
– Explain what approaches can help your child or family member with autism feel calm
– Give clear examples of approaches to routine care tasks that may provoke fear or distress.
– Offer staff alternative approaches to allow for increased cooperation with routine care tasks such as vital signs or fitting equipment that administers oxygen
– Being in the emergency department is stressful. It is very important for
parents/caregivers to remain calm as our children and family members with autism may react negatively to seeing their caregivers visibly upset
– Engage with ED staff to assist them with calming strategies and offering
reassurance
– Caregivers can ask ED staff about bringing preferred tasks, toys, electronics into
the examination room to assist with providing distraction
– Most ED’s are limiting visitors. Families and caregivers should expect that only one person may be allowed to accompany a patient with autism into the ED

3) The points above also apply for patients with autism when they are admitted to the hospital. I often encourage hospital staff, particularly nursing staff to remember that the acute inpatient care setting is NOT the time to try to work on any therapy to treat the autism. The focus needs to be helping patients with autism get through care as safely and effectively as possible. I encourage staff to find out as much as they can about the
patient’s:
– likes/dislikes
– how they communicate
– assistive communication devices – devices can and should be provided in the hospital setting to allow the healthcare team to communicate effectively with patients with autism
– preferred routes for taking medications
– preferred foods
– preferred TV shows
– safety concerns such as elopement, history of removing IV lines or fear of certain procedures
– how they show they are in pain
– how their behavior in the hospital differs from their baseline as this can provide important clues about symptoms that patients with autism may not be able to communicate verbally

4) If a patient with autism is admitted to the hospital we like to have a complete and up to date list of allergies, current medications, dietary supplements or regularly used medical devices such as a CPAP machine or insulin pumps.

5) Sometimes, despite all of our best efforts, patients with autism have a difficult time tolerating the hospital environment and may act out towards themselves or staff. Ask the care team if there is an autism or behavioral specialist on site to assist in their care. If the hospital does not have a behavioral specialist consider inquiring with the healthcare team about including a psychiatric consult to assist in the management of difficult behaviors that may interfere with care.

6) Families may also want to inquire if the care team provide a 1:1 sitter at the bedside to redirect aggressive or impulsive behaviors if a family member needs to step out of the hospital room

7) It is very important that parents/caregivers BE PATIENT with healthcare providers in the acute inpatient setting. Many facilities are likely to be operating understaffed as members of the hospital workforce become ill with Covid-19 and are required to stay home even as hospital census increases during the pandemic.

8) Plan ahead – Hospitals across the country are now limiting visitors. Only one parent or caregiver may be allowed to remain at the bedside with a patient with autism if they are admitted to the hospital.

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a guest blog post by Molly Reilly, BCBA

The term ABA, which means Applied Behavior Analysis, has become one of the most misunderstood if not controversial terms, particularly regarding its use in the treatment of Autism Spectrum Disorder (ASD). Recently, there have been some questions about ABA.  What it is, if it is helpful for individuals with Autism ASD, how do scientists know, can it be harmful, and what is the intent of ABA for behaviors related to ASD?  Molly Reilly, a Board Certified Behavior Analyst (BCBA) from Connecticut, graciously helped explain the fundamentals of ABA with the intention of clarifying the intended use and misconceptions.  

She will begin by defining the practice of ABA. Many people mix up “ABA” with one methodology within ABA, called Discrete Trial Training, or DTT.   Next she will discuss the evolution of ABA interventions including the integration of findings from developmental psychology to create Naturalistic Developmental Behavioral Interventions (NDBIs). These more naturalistic interventions are based in the principles of ABA, but take a more developmental approach.  Finally, she’ll address the concept of punishment and why it should not be used, citing several influential publications in ABA.  Thus, the purpose of this blog is to define ABA, explain how ABA got its start, and how it has evolved into the types of interventions now used in ASDs. 

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“Applied Behavioral Analysis (ABA)…is based on the work of Dr. O. Ivar Lovaas” (Levinstein, 2018, p. 80).The preceding quote illustrates the common misconception that ABA is a single therapeutic approach. The truth is that ABA it is an entire scientific discipline that examines the effects of the environment on behavior with the aim of systematically applying theprinciples of Behavior Analysis to change socially significant behavior (Cooper, Heron, & Heward, 2007). In fact, you can get a graduate degree in ABA! It’s quite complex. ABA has been and continues to be applied to a plethora of issues ranging from smoking cessation (Romanowich & Lamb, 2015), to increasing activity levels (Cohen, Chelland, Ball, & LeMura, 2002), to improving employee’s customer service behaviors (Rice, Austin, & Gravina, 2009).

The relationship of ABA approaches to ASD

 ABA is based on the concept that behavior is influenced by an individual’s environment and their interaction with the environment. This is important because based on years of research in infants, it is clear that babies learn by formulating hypotheses and then testing these hypotheses through their interactions with their environment (Saffran, Aslin, & Newport, 1996).  This learning and skill development is better when it happens in the context of social interactions, so environment and response to that environment matters (Kuhl, Tsao, & Liu, 2003; Yurovsky. Boyer, Smith, & Yu, 2013).  Research also tells us that across ASD and typical development, skills serve as foundations for more advanced skills. Joint attention, for example, is related to subsequent language development (Carpenter, Nagell, & Tomasello, 1998). Therefore, natural sequences of skill development began to be taken into consideration when developing treatment goals. Specifically, skills are taught to children with ASD in the same developmental sequence observed among typically developing children and special emphasis is placed on skills that are foundational to the development of more advanced skills; an example of this would be teaching joint attention to a preverbal child because joint attention is a precursor to language development.  One skill builds upon another, so fundamental skills are taught first, and then it gains in complexity.

Discrete Trial Training – what it is, what it is not, and what that means for the term “ABA”

 Unfortunately, when the average person hears ABA, they think of a child seated at a desk in a sterile room with an adult showing them flashcards and feeding them M & Ms. This grossly inaccurate stereotype of ABA was likely derived fromLovaas’ landmark 1987 study in which he utilizedDTT to teach children with ASD (Lovaas, 1987[i]). DTT is an intensive one-to-one intervention conducted in a highly structured environment that applies basic principles of operant conditioning. DTT aims to teach appropriate behaviors by breaking a task down into a number of small discrete trials and then training the client to master each progressive step until they can complete the entire task. Each discrete trial consists of the following components: cue, prompt, response, consequence and inter-trial interval. A cue is a stimulus in the environment signaling the availability of reinforcement contingent on a particular response. A prompt is assistance provided to help the student engage in the target behavior Response refers to the behavior that occurs following the cue. Consequence is the event following an individual’s response (The Inter-trial interval is a brief pause between trials during which teacher typically records data and sets up materials for the next trial (Lovaas, 1987; Smith, 2001). An example of how the five components may look in a DTT teaching trial is depicted in the table below

CueTeacher places 3 flashcards of animals on table and verbally instructs student to “touch dog”
PromptTeacher points to the flashcard of a dog
ResponseStudent touches the flashcard of a dog
ConsequenceTeacher praises student by saying “nice job touching dog!” and gives the student a skittle. 
Inter-trial intervalTeacher records data and places three different flashcard on the table

Lovaas (1987) published findings from his seminal study in which children with ASD exhibited striking improvements following intense one-to-one DTT training.  Specifically, Lovaas (1987) reported that 47% of participants who received 40 hours per week of one-to-one DTT for two or more years achieved normal educational and intellectual functioning. The remarkable improvements reported by Lovaas (1987) demonstrated the effectiveness of applying these type of techniques such as prompting and reinforcement to teach skills to young children with ASD.  This publication is perhaps the most well known study of any ASD intervention study to date.

The truth is that ABA started long before Lovaas published his dramatic results. In fact, the foremost peer-reviewed academic journal for ABA, The Journal of Applied Behavior Analysis,(JABA)  was first published in 1968 – and there were publications even before 1968.  The debut issue of this journal featured an article by Baer, Wolf, and Risley (1968) advising that ABA should be among many things to promote generalization of skills.  This does not mean ABA is exclusive to DTT.  Clinicians want behaviors to be learned in a variety of environments, not just the clinic.   A therapist teaching a child to identify a cow by repeatedly presenting the child with a flashcard of a cow while they are seated across from each other at a table in a distraction free room will not generalize because it is likely that the child will only be able to identify a cow when they are shown a flashcard picture of a cow by their therapist at the desk. In order for the skill of labeling a cow to be considered generalized,the child should be able to identify a picture of a cow in a book with his sister, a cow on the farm with his peers, and a stuffed animal as a cow at home with his grandmother, etc.  

To summarize, DTT can be quite useful as an initial strategy to introduce a basic skill or concept (especially for individuals who are unable to otherwise learn in a less structured setting). Yet, behavior ultimately needs to be shaped and adapted to naturalistic contexts and, for this, other strategies are needed.

Naturalistic Developmental Behavioral Interventions (NDBIs) – making principles of ABA accessible in a variety of settings across ages

Researchers, noting the limitations of DTT, modified the highly structured DTT approach because each person has a different motivator and needs to learn in a variety of settings.  It is important to state that NDBI are based in ABA and therefore incorporates a number of behavioral techniques including those that precede or motivate and those that reinforce or support behavior. Some of the main differences between DTT and NDBIs are listed in the table below.  They include child choice and interests rather than teacher-initiated sessions.  They also include interspersal of tasks incorporating skills that are already in the child’s repertoire. Researchers like Dunlap (1984) found that interspersing maintenance tasks with acquisition tasks led to faster achievement of skills as well as more positive affect in comparison to presenting only acquisition tasks. This decreases frustration and increases motivation.   

 As mentioned earlier, skills learned in one setting may not transfer to another, so one major criticism of DTT has been that something learned in a clinic does not necessarily help in outside settings (McGee, Almeida, Sulzer-Azaroff, & Feldman, 1992).  Therefore, NDBIstake place in the natural environment; instead of teaching sessions occurring in distraction free room, teaching sessions occur in a variety of settings such as the playground, home, and school.   They also use reinforcers that are more closely related to the behavior.  For example,rather than giving a child an m&m for saying ball when shown a picture of a ball, the child is given a ball to play with upon saying ball after you hold up a toy ball. Naturalistic developmental behavioral interventions teach individuals that are present in the child’s daily life (e.g. caregivers, peers, teachers) to implement teaching strategies in order to promote generalization. Bruinsma, Minjarez, Schreibman, and Stahmer (2019) identified and described common elements of NDBIs including: Environmental arrangement to promote interactions and learning, the use of natural and direct reinforcers as well as other motivational procedures, utilization of prompting and prompt fading when teaching new skills, use of turn-taking within teaching episodes, the use of modeling, adult imitation of the child’s language, play, or body movements, broadening the child’s attentional focus, and perhaps most importantly, an emphasis on child interests and initiations (e.g. child choice, following the child’s lead, etc.).  

 As demonstrated by the information provided above, naturalistic behavioral interventions clearly differ from DTT. Schreibman and Ingersoll (2005) and Delprato (2001) discuss a number of important ways in which naturalistic behavioral strategies differ from more structured behavior techniques and these differences are illustrated in the following table:

Teaching opportunitiesTeacher-initiatedChild-initiated
Learning environmentStructured learning environment (e.g. Sessions are conducted at a table)Natural environment sessions are conducted various locations in the natural environment including home, school, community, or workplace
MaterialsSelected by teacher and remain the same within an activitySelected by the child and frequently change within an activity
ReinforcersReinforcers are unrelated to the target response (e.g. skittle for saying ball when shown a flashcard picture of a ball)Reinforcers are natural and directly related to the target response (e.g. access to a toy ball for saying ball when shown a ball)
Selection of target behaviorsBehaviors selected by practitioners for intervention with the goal of making the child appear as “normal” as possible. Behavior selected for intervention chosen by a team including the parents and individual with possible with the goal of the behavior being socially significant.
Skill presentationA single acquisition skill is taught in isolation through the repetition of teaching trials.Multiple skills are targeted in a therapy session including the interspersal of maintenance and acquisition tasks
ReinforcementOnly correct responses or successive approximations lead to reinforcement. Attempts to respond as well as correct responses lead to reinforcement.
Compiled from DelPrato 2001; and Ingersoll, 2005

Punishment – not what you think it is

The technical definition of punishment in terms of ABA is any stimulus that is presented after a behavior occurs that reduces the behavior. For example, if instructing Tommy to “stop” when he runs into the street results in him no longer running in the street, then the instruction “stop” was punishment.  But there have been reports of other types of punishments that include aversive techniques, such as aggression, verbal abuse, or electroshock.  Some people with ASD have claimed negative long term consequences following ABA, owing the distress aversive techniques that were originally used in Lovaas’ early studies. However, aversive techniques were determined to be harmful and removed from DTT and other ABA treatments for ASD (reference needed here). Unfortunately, given this history, many individuals with ASD continue to associate ABA/DTT to any influence that discourages behavior that is not seen as dangerous. here have also been comparisons between gay conversion therapy and ABA used for ASD.  The professionals highly discourage punishment in any form, in fact, you can read the specific language below:

The behavioral analyst certification board’s stance on punishment

The BACB specifically addresses the use of punishment in its Professional and Ethical Compliance Code for Behavior Analysts in section 4.08, which states: 

4.08 Considerations Regarding Punishment Procedures. (a) Behavior analysts recommend reinforcement rather than punishment whenever possible. (b) If punishment procedures are necessary, behavior analysts always include reinforcement procedures for alternative behavior in the behavior-change program. (c) Before implementing punishment-based procedures, behavior analysts ensure that appropriate steps have been taken to implement reinforcement-based procedures unless the severity or dangerousness of the behavior necessitates immediate use of aversive procedures. (d) Behavior analysts ensure that aversive procedures are accompanied by an increased level of training, supervision, and oversight. Behavior analysts must evaluate the effectiveness of aversive procedures in a timely manner and modify the behavior-change program if it is ineffective. Behavior analysts always include a plan to discontinue the use of aversive procedures when no longer needed. (Behavior Analyst Certification Board, 2014)

NDBss on Punishment

The NDBI handbook (Bruinsma et al, 2019) discusses the disadvantages of punishment including: 

Punishment teaches a child what not to do but not necessarily what to do. Therefore, punishment is not a stand-alone procedure because it should be accompanied with teaching another response. For example, an educator says “no” to Francie when she wiggles her hands in front of her face (the “no” serves as a punisher because she stops the finger wiggling), but Francie needs something else to do with her hands. Thus, the educator might reward Francie with verbal praise for using her fingers to do a puzzle or clap her hands to music. Finally, using only punishment procedures to reduce challenging behavior can lead to poor generalization, as behavior change only occurs when the punisher is present. Generally, NDBIs favor the use of antecedent and rewards strategies and limit the use of punishers (p. 199).

Putting it all together

 Thanks to scientific advances in both ASD and atypical and typical child development, clinicians have been adapting, updating, and developing behavioral interventions for ASD, using the principles of ABA as a guide. ABA does not need to be synonymous with any particular procedure or strategy within its domain.  Punishment such as pain-inducing stimulus like electroshock or other physical abuse is not tolerated and should never be used. However, the principles of ABA have been used to lead to demonstrated improvements in functioning in people with ASD. There is always room for improvement in tailoring each type of intervention with each person.  Below are some real life vignettes of the differences between DTT and NDBI

What happens in real life – some examples of ABA in action

Discrete Trial Training:  

Mario is a 32-month-old boy with an ASD who is currently working on identifying letters. He is his seated at a small table and chair with his therapist who places three letter flashcards on the table (A, F, and P) and verbally instructs him to “touch the letter A”. Mario touches the flashcard with the letter “A” and his therapist reinforces his behavior by saying “good job!” and giving him a skittle to eat. The therapist then begins setting up for another trial by placing three different letter flashcards on the table.

NDBI:  

Billy is a 36-month year old boy with an ASD who is currently imitating phrases and loves playing with cars. His team is currently teaching him to ask initiate social interactions by asking “what’s that?” and to work on this skill his therapist places one of his favorite red fire truck in a brown bag prior to the visit and when she arrives she takes out the bag, shakes it, and models the question “what’s that?” Billy imitates “what’s that?” and his therapist excitedly takes out the firetruck while stating “red fire truck!” Billy excitedly takes the red fire truck and drives it down a garage ramp. His therapist follows him to the ramp, picks up a blue car, and sends it down the ramp while saying zoom zoom! Billy giggles, picks up the blue car, and drives it down the ramp while saying, “zoom!”. His therapist picks up the red fire truck and blue car, holds them both up to Billy and asks: “Red fire truck or blue car?” Billy responds “red fire truck” and his therapist rewards his response by giving him the red fire truck to play with. 

Alexa is a 26-month-old girl diagnosed with ASD and currently uses one to two word phrases to communicate. One morning she walks up to her toy shelf retrieves a closed bin containing musical instruments. Alexa sits down tries to open the container but when she is unable to open the container her mother prompts her to request help by holding out her hand and asking “Need help?” Alexa hands her mother the container and says, “Help”. Her mother immediately opens the container while saying “open” and then hands the open container to Alexa who eagerly takes out a bright pink maraca and shakes it, her mother narrates Alexa’s actions by saying “shake shake shake” and then takes a blue maraca and imitates Alexa’s shaking. Alexa, smiles at her mother and says, “shake shake shake” while shaking her maraca. Alexa’s mom again joins Alexa shaking her maraca while saying “shake shake shake” and the two smile and giggle. Alexa’s mother then holds the maraca above her head and says “shake high!” in a high pitched voice and then continues to shake the maraca and she bends down and says, “shake low” in a deep voice. Alexa smiles at her mother’s silly actions and imitates shaking her maraca up high while saying “shake high” and then shaking her maraca down low while saying “shake low”. 

References: 

Baer, D.M., Wolf, M.M., & Risley, T.R. (1968). Some current dimensions of applied behavior analysis.Journal of Applied Behavior Analysis. 1, 91-97.

Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for behavior analysts. Littleton, CO: Author.

Bruinsma, Y.,  Minjarez, M., Schreibman, L., and Stahmer, A.C. (2019). Naturalistic Developmental Behavioral Interventions for Autism Spectrum Disorder.Baltimore, MD: Paul H Brookes Publishing.

Carpenter, M., Nagell, K., & Tomasello, M. (1998). Social cognition, joint attention, and communicative competence from 9 to 15 months of age. Monographs of the Society for Research in Child Development, 63, 1-142.

Cohen, S. L., Chelland, S., Ball, K. T., & LeMura, L. M. (2002). Effects of fixed ratio schedules of reinforcement on exercise by college students. Perceptual and motor skills94(3_suppl), 1177-1186.

Cooper, J.O., Heron, T.H., & Heward, W.L. (2007) Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education Inc.

DelPrato, D.J. (2001). Comparisons of discrete-trial and normalized behavioral language intervention for young children with autism. Journal of Autism and Developmental Disorders,  31, 315–325.

Dunlap, G. (1984). The influence of task variation and maintenance tasks on the learning and affect of autistic children. Journal of Experimental Child Psychology37(1), 41-64.

Kuhl, P. K., Tsao, F. M., & Liu, H. M. (2003). Foreign-language experience in infancy: Effects of short-term exposure and social interaction on phonetic learning. Proceedings of the National Academy of Sciences, 100, 9096–9101.

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Females with autism show opposite neurobiological features of autism, while alsopossessing some of the same core features of ASD. In females, these differences may be foundinthe way symptoms present or in associated features of ASD.Lack of differentiationclouds important scientific discoveries, which is why treatments and services should besex specific.

Over the past five years, ASD research has increasingly focused more attention on identifying and understanding how autism manifests in females; this includes, but is not limited, to: genetic makeup, symptom presentation, long term trajectory and mental health issues. Females are diagnosed 4x less often but also have an increased load of genetic mutations, including recessive mutations47. This year, results of studies have been mixed in terms of the magnitude and nature of sex and gender related symptom presentation in males vs. females, noting a problem plaguing ASD research mentioned earlier: heterogeneity48. Differences across sex and gender are not seen in terms of presence or absence of symptoms, but rather in the way they present across different ages49,50. On the whole, differences are few in infants and toddlers but are magnified during adolescence, even in the way people perceive ASD symptoms in males and females51. Some scientists suggest that associated symptoms are most likely to present differently than core symptoms of ASD52, with females showing a higher prevalence of ADHD53and OCD, leading to differences in the way males and females appear. 

In addition to findings of increased numbers of recessive mutations in the genome of females47, analysis of brain structure has revealed sex differences further suggestive of the female protective effect. Focused study of the cerebellum has revealed that female activation patterns oppose those of males with ASD 54and fail to evince similar patterns of connectivity across different brain regions55,56, i.e.  females with ASD show reduced connectivity compared to females without ASD, an effect not seen in males with ASD55. In addition, when comparing twins, females had more profound differences in the sizes of  brain regions compared to males57. These findings have led researchers to refine how they examine the role gender plays in basic science research.  

Animal model research suggests that environmental exposures may not produce the same impairments in male vs. female offspring58. Taken together, these biological findings demonstrate that females, despite demonstrating a lower prevalence of ASD, also show complicated behavioral features and more biological markers for ASD. Future research must focus on why females are diagnosed less often than males and why, when they are diagnosed, they present more behavioral markers than their male counterparts.

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Researchers have determined that of the over 100 autism genes that exist, all act on early developmental functions and lead to diverse, overlapping outcomes, including psychiatric disorders, autism, and related conditions. Some genetic influences, while rare, can help define the mechanisms that lead to brain cells in autism developing over time. Although a link has been established connecting environmental influences to this same spectrum of conditions, few studies have successfully defined their interaction. These findings have implications for interventions and could lead to strategies for mitigating symptoms.

Given the comorbidity of mental health disorders with autism spectrum disorder, it should come as no surprise that new research reveals that ASD relevant genes act in fundamental ways that may influence multiple outcomes, ranging from ASD to schizophrenia, to ADHD27-30, neurodevelopmental disorders and intellectual disability31-33. Genes that act on such early and fundamental brain pathways have downstream effects on a number of brain functions, ASD being one of them. This might explain why there are so many ASD genes and why they are pleiotropic, meaning they have different functions. In fact, the list of genes associated with ASD keeps growing, as larger studies and better technology have revealed over 150 ASD associated genes34.   Infant siblings of children with autism also show rare and common gene variants in ASD genes that can aid in a diagnosis9.  

In addition, the presence of certain genetic mutations in ASD relevant genes can produce profound disabilities, which alone work to explain an ASD diagnosis. These mutations, referred to as rare genetic variants, are important to the community because their discovery has led to the creation of Patient Advocacy Groups that provide support and resources for focused research, as well as offer pathways to better understanding the basic circuitry of certain ASD behaviors35. Scientists are studying these rare genetic forms of ASD to understand all forms of ASD, particularly gene expression in the brain36,37. When compared to studies of the brains of people with bipolar disorder and schizophrenia, studies of brain tissue in people with ASD reveal overlapping genetic activity in genes that control synaptic signaling, neurotransmitter release, and immune response.36,37. The abnormal immune signaling in the brain might result in cell damage, as evidenced by accumulation of T-cells in brain tissue38. Studying the brains of people with ASD is the best way to understand the basic cellular and molecular basis of ASD, and is only possible through families who decide at the most difficult time to make the decision to donate. If you would like to learn more about the Autism BrainNet, which made these studies possible, visit www.takesbrains.org/signup

While genetic factors are incredibly important in the diagnosis and presentation of symptoms of ASD, understanding the role of environmental factors in both the diagnosis and presentation of symptoms of ASD is crucial. One of the most studied environmental factors in ASD is exposure to air pollution during pregnancy. This year, ancillary evidence taken from additional locations via different methodologies shows a particular effect for a component in air pollution called PM (particulate matter) 2.5 (2.5 microns)39.  Air pollution exposure may interact with maternal diabetes, which also increases the probability of ASD40.  Air pollution also seems to influence an ASD diagnosis more strongly in boys41. It is important that public health policy address established, scientifically based environmental factors to address even smaller, but preventable, environmental factors. 

There have been spurious reports of other environmental factors, but rather than look at factors in isolation, it is crucial to understand how these factors collectively influence brain development and interact with genetic susceptibility, either rare genetic or polygenic influences36. Another area of convergence of environmental and genetic factors is epigenetics, often called the “second genome”. The epigenome is a multitude of chemicals and tags on the DNA genome that is responsive to environmental factors that can turn on or turn off DNA expression, as early as when the embryo is formed. ASD risk genes identified in genetic studies can also work epigenetically42-46The next generation of research will hopefully focus on understanding the multifactorial influences of an ASD diagnosis, how these factors affect symptoms and influence long term trajectories across neuropsychiatric diagnoses, including ASD.

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The high rate of mental health disorders in both children and adults with ASD means that a large percentage of this population and their families are burdened with enormous challenges Training community providers to deliver mental health interventions shows promise for alleviating these comorbidities. Clinicians need to be on the lookout for these psychiatric issues so people with autism receive the much-needed services they deserve.

While the core symptoms of ASD often lead to challenges in daily functioning, across the lifetime and spectrum of many individuals with ASD, co-occurring mental health conditions are a huge concern. Several older but smaller international studies provide a wide range of estimates of the prevalence of co-occurring conditions. A met- analysis and systematic review of these studies conducted in 2019 has helped to decipher the findings20. The findings revealed 28% comorbidity of ADHD (higher in kids than adults), 20% for anxiety disorders, 11% for depression and 9% for obsessive-compulsive disorder20. There is even overlap in brain based profiles of different diagnoses, both in terms of genetic activity21and structure22. These mental health issues, particularly anxiety, can lead to an acute crisis requiring hospitalization23. Unfortunately, clinicians have limited knowledge and understanding of the nature of these mental health conditions in ASD24, making intervention difficult. However, ASD researchers have had luck training community mental health providers to deliver interventions focused on addressing these mental health challenges25. Training community based providers is a move in a promising direction, allowing more people to receive services in a variety of settings, but the efficacy of these interventions still lags behind those delivered in clinics26. Understanding the high co-occurrence of mental health issues helps families and individuals both plan for later health care needs and anticipate potential mental health problems before they occur.

full reference list at: https://autismsciencefoundation.org/key-autism-research/https-autismsciencefoundation-org-key-autism-research-2019-the-year-of-preparing-for-the-future/

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