UPDATE ON AUTISM SPECTRUM

DISORDERS: ETIOLOGY AND

INTERVENTION STRATEGIES

Gail J. Richard, Ph.D. CCC-SLP

Professor Emeritus,
Director, Autism Center
Eastern Illinois University
gjrichard@eiu.edu
 Disclosures
• Financial
• Honorarium from EIU
• Royalties on publications with ProEd
(LinguiSystems) and Dynamic Resources
• Revenue from courses with MedBridge

• Non-Financial
• Dr. Richard serves as President of the ASHA
Board of Directors
 Current Status of Autism Spectrum Disorder

Autism: Leo Kanner, 1943 “Self”

Prevalence: 1 in 68
30% increase from 2012 to2014
no change from 2014 to 2016
(Center for Disease Control, 2016)
Gender Ratio: Higher Incidence in Males (5:1)
Males: 1 in 42
Females: 1 in 189
Siblings: Increased prevalence (19%)
Increased risk in twins
Different genes for ASD in boys and girls
• Multiple genes contribute to autism
• Biological difference in autism for females vs.
males
• Many disorders have a male predominance pattern
• Genetic transmission Male XY vs Female XX
• Males have single X chromosome; girls have two – carrier or cancel

• Evidence of multiple genetic subtypes

• Show support for autism gene on chromosome 7
• Less compelling evidence for gene on
chromosome 3,4,11
Advance for SLP-August 14, 2006 (p.10,50) Washington Autism Center
Schellenberg, G., Wijsman, E., & Dawson, G.-Molecular Psychiatry Online
-8-1-06
Operational Definition: AUTISM

A PHYSICAL DISORDER OF
THE BRAIN THAT CAUSES A
LIFELONG DEVELOPMENTAL
DISABILITY

POWERS, 1989, 2000

Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition

American Psychiatric
Association,2013;
 DSM 5: Autism Spectrum Disorder
• A. Persistent deficits in social communication and social interaction
across multiple contexts, as manifested by the following, currently or
by history
• Deficits in social-emotional reciprocity
• Deficits in nonverbal communication behaviors used for social interaction
• Deficits in developing, maintaining, and understanding relationships

• B. Restricted, repetitive patterns of behavior, interest, or activities, as

manifested by at least two of the following, currently or by history
• Stereotyped or repetitive motor movements, use of objects, or speech
• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of
verbal or nonverbal behavior
• Highly restricted, fixated interests that are abnormal in intensity or focus
• Hyper- or hypoactivity to sensory input or unusual interest in sensory aspects of
the environment
Note: Must specific severity in A & B using chart, based on social communication
impairments and restricted, repetitive patterns of behavior.
Intervention: Try to move from level 3 or 2 to 1

Severity Level Social Communication Restricted Repetitive

Behaviors

Level 3: Requiring very (description) (description)

substantial support

Level 2: Requiring (description) (description)

substantial support
Level 1: Requiring (description) (description)
support
 DSM 5: Autism Spectrum Disorder
• C. Symptoms must be present in the early developmental period (but may
not become fully manifest until social demands exceed limited capacities, or
may be masked by learned strategies in later life).
• D. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning
• E. The disturbances are not better explained by intellectual disability or
global developmental delay. Intellectual disability and autism spectrum
disorder frequently co-occur; to make co-morbid diagnoses of autism
spectrum disorder and intellectual disability, social communication should be
below that expected for general developmental level

Specify if:
• With or without accompanying intellectual impairment
• With or without accompanying language impairment
• Associated with known medical or genetic condition or environmental factor
• Associated with other neurodevelopmental, mental, or behavioral disorder
• With catatonia
Changes in DSM 5
• ASD is less associated with intellectual disability
• 40% have mental impairment (decreased from 75% in DSM-IV)
• 60% (majority) have normal intelligence

• 54-70% of individuals with ASD have at least one co-morbid

condition (Autism Speaks, 2017)

• Single spectrum but with great individual variability

• Severity of ASD symptoms
• Pattern of onset and clinical course
• Etiological factors
• Associated conditions; can specify co-morbid conditions
• Individual strengths and weaknesses
DSM -5 Mislabeled the Disorder?
• Spectrum implies different degrees of a single
disease entity
• Autism is NOT a single disease entity
• Results from altered neuropathways in the brain
• Found in many different genome configurations;
no one gene is 100% of autism cases
• Many possible comorbidities
• No unique disorder entity that is autism
• Should be autistic syndrome disorder
• Coleman, M. & Gillberg, C., 2012
 Federal Definition of Autism
Individuals with Disabilities Education Act, P.L. 101-
476, section 330.7 (b)(1)
“Autism” means a developmental disability significantly affecting
verbal and non-verbal communication and social interaction,
generally evident before age three, that adversely affects the
child’s educational performance.
Other characteristics often associated with autism are
 engagement in repetitive activities & stereotyped movements
 resistance to environmental change or change in daily routines
 unusual response to sensory experiences
 Primary Symptoms
Communication 40% mute / nonverbal / apraxia
Echolalia Perseveration Jargon Monotone
Delays & Differences
Social interaction Abnormal Relationships
Difficulty relating to self, others, environment
Stereotyped Behaviors Rituals & Routines
Insistence on sameness
Abnormal Sensory Response Hypersensitive
Hyposensitive
Present at Birth
 Autism is Lifelong Disorder
• Research suggests etiology of autism
based in DNA
• Not caused post-birth; happens before born
(NOT diet, vaccinations)
• Intervention can positively impact evolution
of the disorder, mitigate severity of
symptoms
• Cannot “cure” the disorder
• Symptoms should modify with age and
treatment
Autism Genome Project
• 137 leading scientists at 50 academic institutions
worldwide
• Analyzing DNA from 1,600 families with children
who have autism
• Attempting to identify specific group of brain cells
and genes that affect development and function
• Focus on region on chromosome 11, family of
genes involved in communication between
neurons during brain development

Nature Genetics – February 18, 2007

ASD Data from Human Genome Study
• ASD polygenetic – heterogeneous neurodevelopmental
complex inherited disorder
• Monogenetic – Fragile X and Rett’s
• Continuum of neurocognitive features with shared aspects
• Different types of mutant genetic changes associated with
ASD
• Severe loss of synaptic connectivity
• Diverse levels of genetic buffering, pruning
• Genetically based metabolic differences
• Abnormality in brain structures and/or function during
development
New Research Breakthroughs
• Polychlorinated biphenyls (PCBs)
• Found in many consumer product (e.g., plastics,
electronics)
• Disrupt normal patterns of neural connections in
brain
• Exposure leads to overabundance of dendrites
and disrupts neuronal connection patterns

ASHA Leader, June 5, 2012

 Increased ASD Risk Factors
• Paternal Age
• Children of men age 40 and older – significant increased risk than
those under 30 -6 times greater
• Older age in mothers not associated with autism
• Question spontaneous mutation in sperm
Archives of General Psychiatry – Sept 2006

• Maternal use of Antidepressants during pregnancy

• Antidepressant use during 2nd and 3rd trimester may have 87%
increased risk of having child with autism
• Selective serotonin reuptake inhibitors (SSRIs) particularly
associated with ASD diagnosis
• Serotonin involved in numerous pre and postnatal developmental
processes, including creation of links between brain cells
JAMA Pediatrics, 2015
No Correlation with Vaccinations and ASD
• Danish Study suggests no link between autism and
thimerosol
• Eliminated from vaccines in 2001; no decline in incidence
of autism
• Non-vaccinated children at greater risk to contract viral
infections
• Estimated 1 in 4 children in US in compliance with
vaccination guidelines due to fear of ASD

Advance SLP/A-October 31, 2005 (p.17)

 Etiological Variables
Genetic • Environmental Factors
• Autosomal • Toxins; Gene Mutation
dominant/recessive • Trauma
• Sex-linked
• Diets; Foods
dominant/recessive
• Radiation
• Lead
• Chemicals in Groundwater

•Multifactorial Inheritance
•Environmental Factor & Genetic Interaction

“Empirical research has convincingly shown that neurobiological

factors are of critical importance in its (autism) causation”
Luke Tsai, M.D.
 “No two autistic children are
alike… The goal is to observe
and find the specific pattern of
response each child exhibits…”

Temple Grandin

Emergence:
Labeled Autistic
 Primary Behavioral Characteristics
 Reciprocal Social Interaction Deficits
 Averted or indirect eye contact
 Minimal facial expression and use of gestures
 Lack of join attention on focus on others
 Egocentric verbal and social interactions
 Communication Impairments
 Developmental apraxia of speech
 Echolalia, verbal perseveration
 Monotone, robotic vocal prosody
 Literal /concrete in language acquisition and interpretation
 Restricted Repetitive Patterns of Behavior
 Self-stimulatory movements
 Motor perseveration and/ or fascination
 Obsessive preoccupation and attachment to items
 Reliance on routines and rituals
Sensory System Differences
• Hyper (over) and Hypo (under) responsiveness to sensory
stimuli
• Tactile defensiveness
• Hyperacusis
• Picky eating
• Self-regulation problems with sensory stimulation
• Fail to modulate volume
• Seek inappropriate sensory stimulation
• Hypotonia
• Low muscle tone
• Fine motor deficits
• Gross motor deficits
 Challenge to Diagnose
Developmental Delays
• Good observation assessments/tests
• No definitive medical test (i.e., blood test,
chromosome analysis) for autism spectrum
• Rely on knowledge of behavioral
characteristics to compile profile that meets
diagnostic criteria
Need to screen all children for ASD at 18 & 24 months as general wellness
checks

• Should be identifying by 24 months – now down

to 18 months
• Median age of diagnosis has increased; now at 5 years
• Estimate lifetime society cost is 3.2 million per
child w/autism – most in adulthood
• Can reduce by 67% with early intervention (Autism Society of
America)
• Early Intervention
• Greatest impact on ASD is before 3 yrs
• 80% of children who need early intervention are missed
• Early intervention can reduce annual education cost by $10,000
per child if attend regular kindergarten
 ASD Screening: Pediatricians Unfamiliar with Tools

• Few pediatricians screen regularly for ASD

• Lack familiarity with ASD screening tools
• Of those who reported screening for ASD, 905
prompted by parent concerns
• Of 255 in Maryland & Delaware, 82% screen for
developmental delays, but only 85 for ASD

Journal of Developmental & Behavioral Pediatrics – April 2006-Dos Reis, S

Most referrals for ASD testing initiated by
parents who notice developmental differences
Challenge in Pediatric Developmental Disorder
Diagnosis

• Acknowledge genetic biochemical etiology

• Brain maturational lag – delay in myelination;
connection between temporal and frontal lobes
• Disconnect between treatment/ intervention
(behavioral) and cause (biological)
• Match educational and medical intervention efforts
with primary symptomatic deficits
• Challenge with diverse genomic variations of
autism and developmental language disorders
 BEHAVIORAL
OBSERVATION

REALITY CONTACT

WITHDRAWAL SOCIAL
RECIPROCITY
SENSORY DIFFERENCES
RITUALISTIC
ECHOLALIA
MENTAL RIGIDITY
PERSEVERATION
SELF-STIMULATION
CHILDREN WITH AUTISM
DEMONSTRATE
BEHAVIORS THAT
CANNOT BE CHANGED.
S ENSORY
YSTEM
 SENSORY INTEGRATION

“The neurological process that organizes

sensation from one’s own body and from
the environment and makes it possible
to use the body effectively within the
environment.”

Jean Ayres, 1979

 Sensory Integration
 Designed to build up filtering
 Desensitization is to balance excitation
and inhibition
 Myelin – insulation on axon so stimulus
propelled more efficiently and
accurately
 Pruning process defective (over and
under) – leads to brain that has trouble
adapting to world
 Individual Differences
 Understand how neurological systems reacts and
interprets stimuli
 Individual Differences (Greenspan & Wieder (1998)
 sensory modulation (hyper / hypo responsiveness)
 processing
 motor planning & sequencing
 Nature vs. Nurture Dance
 Brain partially wired at birth; Rest occurs after birth;
genes & environment interact together
 Plasticity through puberty
 Support biology to overcome /compensate for deficits
 Brain creates itself through experiences; every
experience helps create connections
 ABERRANT SENSORY
SYSTEM RESPONSES
HYPER-RESPONSIVE HYPO-RESPONSIVE

Taste Sight

Smell Hearing

Movement Touch

Muscles Vestibular Light Touch Deep Touch

& Organ Temperature or Pressure
Joints Richard, 1997
 TACTILE SYSTEM
skin receptors
 Light Touch
 reactive, protective, primitive, very sensitive
 can’t be ignored (e.g., itch, hair)
 Discriminative Touch
 under-developed; ability to differentiate by feel
 densest in oral cavity
 oral exploration, chewing
 hypersensitive = picky eating, oral defensiveness
 Temperature - cold, heat, pain
 hyposensitive; hard to discriminate
 often feel the same initially
VESTIBULAR SYSTEM
 Inner ear; responds to gravity, weight
changes, position in three planes
 Stimulate by moving head; don’t have
to move whole body
 90% of cells in visual cortex also
respond to vestibular system
 85% of material presented for learning
is visual in the early years
 VISUAL SYSTEM -
optical
 Peripheral Vision versus Focal Vision
 Peripheral = primitive, early vision; fight or
flight
 Focal / Central = higher level visual
development
 Developmental
 Watching marble in a maze helps develop focal
vision
 Watch to see if child using eyes together or
alternately - need both eyes for depth perception
NEUROLOGICAL CONNECTION

CORTEX
PROCESSING

RETICULAR FORMATION
SCREENER AROUSAL

VESTIBULAR SYSTEM
Richard, 1997
Biochemical Teeter-Totter

Endorphins

Anxiety

Anxiety

Endorphins
 Pendulum of Emotions

Ov
Low a d er lo a High
erl o d
Energy n d Energy
U
Quiet
Alertness

Optimal Level
Sensory Issues
 Individuality of Sensory Triggers
 Personal Preferences
 Calm Flooding vs. Vigorous
Exercise
 Time Element
 Maintain Biochemical Balance
 INTERNAL VS. EXTERNAL

“The perceptual problems of deafness, muteness, and

blindness are experienced as very real. They are, nevertheless,
caused by extreme stress, brought on by an inability to cope
with emotion. Perhaps this very real perception and the
behavior it leads to are caused by oversensitivity triggering
protective chemicals or hormonal responses in the brain.
Perhaps in something of a vicious circle, this emotional
hypersensitivity in turn leads to developmental problems…which
leaves such children functioning on a far more sensory time and
space.”
-Donna Williams
Nobody Nowhere
 Self-Stimulatory Behaviors
 Rocking, hand-shaking, flicking objects
“Provide security and release, and thereby
decrease built-up inner anxiety and tension,
thereby decreasing fear. The more extreme the
movement, the greater the feeling I was trying to
combat.”
 Laughing

“Often a release of fear, tension, and anxiety

Donna William
Nobody Nowhere
MODIFICATION

“…under overload conditions any of

several meaning systems can shut
down partially or completely, in
combination or isolation. Sensorially,
this can mean that any one or any
combination of the senses can become
extremely acute.”
-Donna Williams
Nobody Nowhere
 Sensory Kit
Alternatives to provide sensory
input without being disruptive /
inappropriate
Brainstorming Session

 Proprioceptive /Vestibular
 Visual

 Auditory

 Tactile

 Olfactory / Gustatory
Strategies for Proprioception:
Contractions of muscles and joints to
mediate appropriate body movements
 Improve body awareness in space
 Therapy in front of mirror – provides
visual
 Pair speech production with motor
movements
 Jump on mini-tramp, say sound/words
 Clap out spelling words
 Climb stairs reciting alphabet
 T-stool, therapy ball, stand at desk
Richard & Veale, 2009
 Strategies for Vestibular:
Information about body in space; mediated
primarily in balance centers of inner ear
 Modify/shape self-stimulatory behaviors
 Engage in bilateral and cross lateral
games and activities
 Movement exercises and activities
 Isometric and aerobic exercise breaks
 Walking, running, treadmill, stationary bike
 Sit and spin
 Rocking chair, scooter board
 Swinging Richard & Veale, 2009
Strategies for Visual System:
Stimuli received in the retina; relatively
concrete for interpretation
 Develop central focal vision
 Use slant board to present material
 Monitor and modify aversive stimuli
 Poor visual perception leads to
distortion
 Handwriting - poor letter formation and
orientation on page
 Reading and interpretation of diagrams
Richard & Veale, 2009
Strategies for Auditory:
acoustic stimuli defined by decibels
(volume) and frequency (pitch)
 Music
 Desensitization to environments
 Barrier noise to control aversive
stimuli
 Teach alternative behaviors to
outbursts
 Use positive to avoid negative

Richard & Veale, 2009

Strategies for Tactile:
density and type of receptors in the skin
 Use deep pressure for calming
 Cape, hat, weighted vest, mat
 Bean bag, “pizza pocket”
 Water play, water table, ball pit
 Wrap up in blanket
 Identify problematic touches
 Desensitize

Richard & Veale, 2009

Strategies for Olfactory/Gustatory:
Smell based in chemical receptors in nasal passages;
taste based in chemical receptors of tongue

 Identify pleasant / like vs.

unpleasant / don’t like
 Desensitize in gradual steps
 Use likes to approach dislikes
 Teach alternatives to inappropriate
outbursts

Richard & Veale, 2009

Sensory/Behavior Management

 Internal vs External Trigger

 Play Detective; Don’t Treat Symptom
 Analyze Behavior (e.g., confusion, control)
 Behavior = Nonverbal Communication
 Legitimate problems
 Be cautious re: quick fix
 Modify / Shape /Sensory ‘Toys’
 Sensory Breaks
 DEAL WITH PRODUCTIVELY
 CLEAR EXPECTATIONS; RULES
 CONSISTENCY
 LOGICAL CONSEQUENCES
 STAY CALM
 REMAIN OBJECTIVE
 SENSE OF SECURITY
 COMFORT ZONE
 ENDORPHIN ACTIVITY
 Sensory Modulation Summary
 Sensory Defensiveness (mild, moderate,
severe)
 Logic Behind Behavioral Disruptions
 Use Sensory System as Facilitator
 Respect Sensory Sensitivity
 Down-Time vs. Time-Out
 Prepare; Pre-warn
 Provide Structure
 Sensory Processing Disorder
• Immature or delayed myelination in
neurological development will result in
sensory system differences
• Sensory deficits can occur independent of
autism spectrum disorder
• Often accompany medical syndromes (i.e.,
Down Syndrome, Fragile X, Rett
Syndrome) and cognitive/intellectual
impairments
Sensory processing abnormalities
• Cross-sectional study examined auditory, visual, oral,
and touch sensory processing as measured by
Sensory profile
• 104 subjects with diagnosis of ASD
• 3-56 years of age
• Gender and age matched to community controls
• ASD had abnormal auditory, visual, touch, and oral
sensory processing significantly different than
controls
• Lower levels of abnormal sensory processing in later
ages
• Conclusion: Global sensory abnormalities in ASD
involving several modalities; potential to improve
with age
Kern et al. 2006
ASD- Prolongation in ‘Temporal Binding Window’

• Brain has trouble associating visual and auditory

events
• Weakness in binding or pairing audio and visual
stimulation
• Hypothesize have difficulty dealing with more
than one sense and a time
• Results in a confusion between the senses

• Stevenson, Siemann, Schneider….et al., 2014

 Issues to Consider
 Don’t judge success/failure too quickly
 Do careful observation of sensory
system
 Justify sensory “toys”
 Balance movement and quiet time
 Routines and structure
 AND …..
 Strategies for
Stimulating Speech &
Language
 LANGUAGE
• Semantics : Word Meanings
• Vocabulary
• Concepts
• Problem Solving & Reasoning
• Syntax & Morphology: Grammatical rules of
structure
• Phonology: Sound production and rules for
combination/usage
• Pragmatics: Social use of language
Promoting Verbalization
 Stimulating Speech Mechanism
• Respiration
• Vocalization
• Articulation
 Stimulating Practice of Speech Models
• Automatic Speech
• Songs
• Creative Drama / Role Play
SAMPLE PROGRESSION
 Objects
 Photographs
 Colored Pictures
 Black & White
Line Drawings
 Printed Words
Wagon
 “As an echolalic child, I did not
understand the use of words because I was
in too great a state of stress and fear to
hear anything other than patterned sound.
The need to hide the fear is such that not
even the face is allowed to show it. The
comprehension of words works as a
progression, depending on the amount of
stress caused from fear and the stress of
directly relating.
-Donna Williams
Nobody Nowhere
 ECHOLALIA
 Normal Stage -Language Development
 Positive Aspects
• ability to produce speech
• ability to model / imitate
• awareness of turn-taking
 Shape from non-meaningful to meaningful
 MEANINGFULNESS RATIO

 Meaningful  NonMeaningful

111 1111
11
 SEMANTIC LANGUAGE
 Functional
Vocabulary
 Conceptual
Language
 Concrete to
Abstract
 Discourse
 Social Information
▪ Kanner’s core shared features include multiple aspects
of social communication deficits
▪ “autistic (i.e., self-absorbed) disturbances of affective
contact” (Kanner, 1943)
▪ Lack of affective interaction, awareness, and contact
with people
▪ Reciprocal social interaction deficits typical of ASD
▪ Poor eye contact
▪ Minimal facial expression, gestures
▪ Lack of initiation for interaction; ignore other people
▪ Lack of joint attention, shared interest
▪ Ego-centric focus; one-sided monologue versus
dialogue
ASD Social Communication Warning Signs
Wetherby & Prizant, 2002
9-12 Months 18 Months 24 Months
• Part of First Words
Project Lack of response to Lack of response to Lack of
name name responsiveness

• http://firstwords.fsu.edu Lack of social smile Lack of shared joy Lack of shared

enjoyment

• www.firstwords.org Poor mutual

attention
Poor joint attention Lack of facial
expression

• Website with information Limited gestures Minimal pointing

or gesturing
Lack of pointing to
share interest

for parents and Poor imitation Unusual prosody to Poor imitation;

speech delayed speech

professionals Poor eye contact Lack of appropriate Abnormal eye

gaze contact
Limited affective Lack of shared Limited interest in
range interest shared games
Extreme passivity Repetitive body Over/under sensory
movements reactions
Poor visual Repetitive Unusual visual
orientation to movement with interests; unusual
stimuli objects play with objects
 ASD and Development:
Early Onset & Regression
• Examination of first and second year
birthday parties
• Worsening of social and/or communication
skills during second year
Archives of General Psychiatry – August 2005

• Molecular studies suggest some autisms

have pattern of normal development
followed by regression between 18-36 mo
Coleman, M. & Gillberg, C., 2012
 Importance of Social Aspect of
Language
• Often overlooked due to complexity and
individualization
• Key factor in prognosis
• Child typically learns to program behaviors to
gain attention and interact with environment and
people
• Generally positive reinforcing experience
• Core feature of autistic spectrum disorder
• Range in severity from complete isolation to
preference for being alone
 Challenges and Impact
▪ Preschool
▪ Need joint attention and eye gaze for acquisition of language
▪ Strong predictor for receptive language development, vocabulary
acquisition (Toth et al. , 2006)
▪ Develop basic interaction skills
▪ Responsiveness to other people and activities (Sullivan et al., 2007)
▪ School Age
▪ Basis of learning – attention, response, and interaction with teacher
▪ Ability to initiative requests for assistance, clarification, information
▪ Peer interaction – share interests, engage in discourse, participate in
shared activities (Bauminger, 2002)
▪ Behavioral problems – misread social cues
▪ Vocational/occupational implications for future career planning
(Lleras, 2008)
 Assessment Options

▪ Comprehensive Assessment of Spoken Language (CASL) Pragmatic

Judgment subtest; Supralinguistic subtests (Carrow-Woolfolk,
1999,2008)
▪ Pragmatic Language Skills Inventory (PLSI) (Gilliam & Miller, 2006)
▪ Pragmatic Protocol (Prutting & Kirchner, 1983)
▪ Social Communication Profile (Garcia-Winner)
▪ Social Language Development Test – Elementary & Adolescent (Bowers,
Huisingh, & LoGiudice, 2008; 2010)
▪ Social Responsiveness Scale-2 (Constantino & Gruber, 2012)
▪ Social Skills Rating System (Gresham & Elliott, 1990)
▪ Test of Pragmatic Language (TOPL) (Phelps-Terasaki & Phelps-Gunn,
1992)
▪ Test of Problem Solving (TOPS) – Elementary(3) & Adolescent (2)
(Bowers, Huisingh, & LoGiudice, 2005; 2007)
Acquisition versus Performance Deficits
Acquisition Deficits
▪ Don’t know the expectation
▪ Don’t know how to execute the
social behavior
▪ Treatment begins with specific
instruction to address the lack of
knowledge for social skill(s) in
deficit
Olson, 2005
Performance Deficits
▪ Don’t perform expected
behaviors
▪ Don’t know when to use the
social skill/ behavior
▪ Dealing with competing internal
behavioral states
▪ Treatment begins with specific
instruction in recognizing and
responding to situational cues
 Sample Hierarchy for Goals in Social Pragmatics
The Autism Spectrum Disorders IEP Companion, Richard & Veale, 2009

Preschool – Early Elementary School Age - Adolescent

• Joint Attention • Conversational Discourse

• Negotiation
• Turn-Taking / Reciprocity
• Persuasion
• Initiation • Narration

• Play • Humor
• Empathy
• Topicalization
• Nonverbal Communication
• Communicative Functions • Facial Expression
• Body Language/Gesture
• Paralinguistics
• Proxemics
• Presupposition
Infant / Toddler – Develop Pretend Play
• Pretend play correlated with language development,
cognitive development, social skills (Watson, 2017)
• Pretend play involved interaction with caregivers
• Responsiveness
• Stimulation
• Engagement

• Development of Pretend Play

• Exploratory Play 2-10 months intentionally grasp object
• Relational Play 10-18 months relate objects to one another
• Functional Play 12-18 months conventional pretend pla
• Symbolic Play 18-30 months object substitution
MAJOR AREAS FOR PRESCHOOL
GOALS

 Pre-academic readiness skills

 Pragmatic social skills
 Oral motor skills
 Fine motor skills
 Gross motor skills
 Adaptive behavior / Self-help skills
 Comments on Schedule

 Balance motor movement & quiet sitting

 Teaching balanced with quiet and motor
 Free play at beginning and end to calm
anxiety
 Sensory motor consistent throughout
 Demands for interaction varied
 Preschool Goals
 To improve nonverbal pragmatic skills to more
age appropriate level
• increase eye contact
• engage in reciprocal play & turn taking
• respond to simple directions
• indicate needs and preferences
• participate in music & language activities
 -To improve verbal pragmatic skills to a more
age appropriate level.
 ELEMENTARY SCHOOL-
AGED GOALS
 To demonstrate age appropriate verbal
pragmatic skills
 To demonstrate age appropriate discourse /
conversation skills
 To demonstrate age appropriate nonverbal
pragmatic skills
School-aged Activities
Social Skills - Social Stories
Group Therapy with Peers
Scripted Routines
Role Play
Carry-Over Assignments
Structured / Unstructured Situations
Community Integration
 ADOLESCENT / ADULT GOALS
 To demonstrate age appropriate functional pragmatic skills
• Verbal Conversational Skills
• Clarification of Messages
 To demonstrate functional problem solving for independent living
• Emergency Situations
• Vocational / Occupational Interactions
 To demonstrate age appropriate daily living skills
• Hygiene & Physical Appearance
• Nonverbal Body Language
 To demonstrate functional executive function skills
• Initiation, closure
• Organization
• Planning
• Problem solving
 COMMUNITY
INTEGRATION

 Talk through Situation

 Research Situation
 Role Play Situation
 Observe Situation in Real Life
 Experience Situation in Real Life
 COMMUNITY / JOB
TRANSITION
 Splinter/savant components can work well in job skills
despite low IQ
• Visual Memory - sorting, stocking
• Visual Motor - assembly
• Attention to Detail - inspection
• Literacy - fill orders
 Challenge to job site is transition to setting, not the job
skills
JOB TRANSITION
Place child in setting

Target Behaviors

Collect Data

Devise Treatment

Train Counselor

Implement Treatment

Evaluate Treatment
Purpose of Social Stories

Carol Gray

Teach social skills in a story format to

improve understanding in specific life
situations.
 Design a Story

 Describe situation’s relevant cues and

appropriate responses
 Personalize and emphasize social skills
 Format in sequence of clear steps
 Use routine to teach students
 Steps for using Social Stories
 Introduce the story with minimal
distractions; Read the story 1-2 times to child
 Review story approximately once a day;
focused review prior to situation occurring
 Monitor student responses when reading
story; make revisions as necessary
 Gradually fade story once part of child’s
routine; decrease review frequency
 Summary Comments
▪ “Social competency is a judgment, not a test score” (Garcia-Winner)
▪ Need to evaluate as naturally as possible, but also have to substantiate to
qualify for services in some settings. Solicit input from different settings and
people to compare social skills
▪ Social communication challenging to assess but one of most debilitating
aspects of autism
▪ Critical to prognosis, both long and short-term progress
▪ Requires direct, sequenced, concrete objectives
▪ “De-mystify abstract communication area
▪ Requires ‘extra’ with community integration
▪ One of most rewarding aspects of communication to address
 Classification System for Intervention
National Standards Project (2009)

• Classification system following research review to

establish evidence-base for treatment decisions
in ASD
• Established: sufficient research evident to suggest
favorable outcome
• Emerging: appears favorable, but research-based
evidence in not consistently conclusive
• Unestablished: little or no evidence to form conclusion
regarding effectiveness - could be effective; could also
be ineffective/harmful
• Ineffective/Harmful: research evidences determines
treatment detrimental or ineffective
Treatment Techniques in Efficacy Categories
Established Emerging Unestablished Harmful/Ineffective
Antecedent Package Augmentative & Academic None
Alternative Interventions
Communication
Behavioral Package Cognitive Behavioral Auditory Integration
Intervention Training (AIT)
Comprehensive Developmental Facilitated
Behavioral Treatment Relationship Communication (FC)
Joint Attention Exercise Gluten &
Casein-Free Diets
Modeling Exposure Package Sensory Integration
Naturalistic Teaching Imitation Interaction
Peer Training Initiation Training
Pivotal Response Language Training
Schedules Massage/Touch
Self-Management Music Therapy
Story-Based Peer-mediated
Intervention Instruction
Picture Exchange
Communication
System (PECS)
Scripting
Sign Instruction
Social
Communication
Social Skills
Structured Teaching
Technology
Theory of Mind
Types of Intervention Strategies
Intervention Type
Environmental arrangements and structure
Picture schedules and visual supports
Written scripts and social stories
Video modeling
Computerized instruction
Previewing learning context and activity
Strategies to promote generalization
Strategies to promote self-generalization
Description/Example
Use preferred materials, sabotage to promote
interaction, space designed for visual clarity
Picture sequences for activity, steps to
complete, pictured choices, visual prompts
Cue cards, prompts for initiation, practice
script until generalized, identification of
relevant aspects of activity, thought bubbles
Recorded highlight of critical features within
situation, visual feedback and example of
desired behavior, relate better to video/object
Teach focused communication aspects, non-
social nature of computer beneficial
Prepare for coming events, decrease anxiety
behaviors
Transfer new skill to natural environment, use
parents, caregivers, field trips
Increase control and independence, make
decisions, express preferences
BEHAVIORIST THEORY

“We may not know what goes on inside

the brain, but we can certainly see what
happens on the outside. Let’s measure
behaviors and learn to modify them with
behavior reinforcers. If we like it, reward
it. If we don’t, punish it.”

Eric Jensen
Teaching with the Brain in Mind
NEUROSCIENCE PERSPECTIVE

“ Today’s brain, mind, and body research

establishes significant links between
movement and learning. Educators
ought to be purposeful about integrating
movement activities into everyday
learning.”

Eric Jensen
Teaching with the Brain in Mind
 Research on ASD Treatment
• ASD brain not as adaptable – neuroplasticity disorder;
don’t adapt to experience
• Repetition is key component of ASD therapy; repetitive, consistent
• Need many, many experiences to change/adapt and modify
“sameness” in behavior
• ABA okay, but shouldn’t be the only therapy
• Need Theory of Mind
• Relate to other’s experiences
• Difficulty to improve social skills in one-on-one therapy room
• Balance fascination with technology
• 80% personal therapy
• 10% or less technology-based
 “ A teacher was my salvation…
didn’t see labels, just underlying
talents. … came into my world.”

LABEL
Temple Grandin

Emergence:
Labeled Autistic
STIMULATION TECHNIQUES

• Stimulate senses, mind, body

• Incorporate unique interests
• Motivate with concrete, functional
items
• Use incentives that impact student
• Channel fixations in constructive way
Multimodality Techniques
• Use visual and tactile stimuli; avoid verbal only stimuli
• Demonstrate rather than verbal explanation
• Vary teaching across sensory modalities
• Be aware of “single channel” learning
• Allow extra time for processing; be aware of latency
between input and output
 ROUTINES
•Schedule
•Define Physical Space
•Demonstrate Tasks
•Modify / Build on Routines
 CHOICES
• Extremes vs. Mutually Desirable
• Sabotage to Promote Interaction
• Sequences to Promote
Independence
• Visual Timers
• Down Time Reinforcement
Choices
Literacy Focus

Visual Organization
Functional
Reality Checks

Repetitive
 VIDEO
Repetition
Increase Models
Home Therapy

Non-threatening
 COMPUTER
TECHNOLOGY
Read with Meaning
Minimize Stress of Relating
Motor Compensation
Alternative Communication
The “dis” in “disability” seemed
written in letters ten feet tall; it
cast a shadow over the fact there
was any ability at all to be found
in that word.”

DIS ability
Donna Williams

Somebody
Somewhere
 TEAM DECISIONS
 Primary Disability Diagnosis
 Deficits and Needs of the Individual
 Professional Services Required
 Educational Goals
 Educational Placement
SUPPLEMENTAL SERVICES
OPTIONS
 Personal Aide
 Speech Therapy
 Occupational Therapy
 Learning Disability Services
 Behavior Consultant
 Social Worker/Counselor
 Psychologist
 Nurse
 Professional Roles
The role which various members play will
vary by setting. Some responsibilities are
obvious to the specific area of expertise.
Other responsibilities evolve, consistent
with personality or skills a person
possesses, regardless of the discipline
represented.
Informal Diagnostic Profile Areas
 Social Interaction relating to self, others, environment
 Communication
• verbal and nonverbal
• receptive and expressive
• semantic and pragmatic
 Motor
• self-stimulatory differences
• gross and fine motor development
• sensory system differences
 Behavior adaptive and maladaptive
 Academics specific academic skill levels
 Cognitive cognitive functioning level ;
both formal & informal assessment
 IEP GOALS
 LANGUAGE
 SOCIAL INTERACTION
 ACADEMIC
 MOTOR
 SENSORY
 BEHAVIOR
 Amount of time in school day

Amount of time engaged in productive

activity with certified teacher

Productivity Ratio
 FULL INCLUSION
 Advantages
 Disadvantages
• Educated in least
restrictive environment
• Exposure to stimulating
models for
communication,
socialization, academics
• Educates teachers and
peers to disabilities
• May compromise
education progress
• Demands of regular
classroom may be too
much, causing anxiety,
frustration, behavior,
poor self-esteem
• if expectations exceed
child’s capabilities,
result is one-on-one
instruction with aide
 HOME
INVOLVEMENT
IEP Goals Parent Concerns
Carryover /Transition Staffings
Team Balance in Decisions
 Toolkit for Adults with ASD
• Autism Speaks – advocacy organization
• Toolkit with free information and guidance to help adults
recently diagnosed with ASD
• “Is It autism and If So, What Next?A Guide for Adults” (
www.autismspeaks.org/adult-tool-kit)
• Help access services and provide information about rights
and entitlements as an adult on spectrum
• Includes personal essays by people diagnosed with ASD as
adults
• Suggestions on how to get evaluation, treatment, services
• Other resources focused on housing, residential support,
employment, transition out of school, postsecondary
opportunities
“Best” Methodology Principles
• Establish routine or schedule
• Modify environment and
accommodate special needs
• Control overwhelming stimuli
• Give individual person space and
freedom
• Allow movement
• Introduce calming stimuli
 Prevention & Intervention issues
• Attend to all aspects of early development (e.g., motor,
speech, social, behavior)
• Conduct early screening to identify “at risk” or document
developmental delay
• Early referral for intervention may prevent or minimize
significant later developmental problems
• Educate caregivers regarding importance of
language/communication intervention
• Requires coordinated and integrated planning and
treatment model
Future of Autism Research
• Some educational methods effective
• Targeted medical therapy is ideal
• Based on accurate diagnosis
• Challenge with diverse genomic variations
of autism
• Entering new age of medicine with focus on
genetic aspect
 Letter From the Teacher
Dear Mrs. Mom,

Today at lunch, Alex threw his juice all over a first grader sitting across the table
from him because he didn’t want to hear her talking to him. Because this is not
acceptable behavior, Alex sat “time out” in the front hall with Mrs. James, the
teacher on lunch room duty during the incident.

Since Alex didn’t get this work finished (from the a.m.), at noon recess because
of his “time out”, I insisted he stay in his second recess to do his assignments.
Also, I didn’t allow him to attend art when the rest of the class went today.
Instead he stayed in the classroom and did some more of his a.m. work.

If he “insists” on “not doing” his assignments (as he has done all day today), I
cannot give him grades and this will eventually result in failure of second grade.

Please sign this note and return it on Wednesday, 10-9. Thank you.

Sincerely,
PLOW THE HAPPINESS
LONELY BOY, DO PERHAPS YOU’LL
NOT FEAR NEVER TALK OR
GOD WILL RUN
APPRECIATE WHY BUT YOU’LL SPREAD
YOU’RE HERE JOY AROUND FOR
EVERYONE
THE SUN DOES
RISE USE WHAT GOD HAS
THE WIND DOES GIVEN YOU
BLOW PLOW THE
I LOVE YOU BOY HAPPINESS
UNDER THE SKY TOO LATE FOR YOU
-David Eastham
 Selected References
• American Psychiatric Association (2013). Diagnostic & Statistical Manual of Mental Disorders, fifth edition. Washington,
DC.
• Ayres, J. (1979). Sensory Integration and the Child. Los Angeles, CA: Western Psychological Services.
• Bauminger, N. (2002). The facilitation of social-emotional understanding and social interaction in high-functioning children
with autism: Intervention outcomes. Journal of Autism and Developmental Disorders, 32(4), 283-298.
• Coleman, M. & Gillberg, C. (2012).The Autisms, Fourth Edition. New York, NY: Oxford University Press..
• Greenspan, S. & Wieder, S. (1998). The Child with Special Needs: Intellectual and Emotional Growth. Reading, MA:
Addison-Wesley.
• Jensen, E. (1998). Teaching with the Brain in Mind. Alexandria, VA: Association for Supervision and Curriculum
Development.
• Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child,2:217-250.
• Kern, J., Trivedi, M., Garver, C., Grannemann, B., Andrews, A., Savla, J., Johnson, D., Mehta, J., & Schroeder, J. (2006).
The pattern of sensory processing abnormalities in autism. Sage Publications and the National Autistic Society Vol. 10 (5),
480-494.
• Lleras, C. (2008). Do skills and behaviors in high school matter? The contribution of noncognitive factors in explaining
differences in educational attainment and earnings. Social Science Research, 46, 21-30.
• Powers, M. (2000). Children With Autism: A Parent’s Guide – 2 nd ed. Bethesda, MD: Woodbine House.
• Reisman, J. & King, L. J. (1993). Making contact: Sensory Integration and Autism. Peoria, IL: Continuing Education
Programs of America.
• Richard, G. (1997). The Source for Autism. East Moline, IL: LinguiSystems.
• Richard, G & Veale T.(2009).The Autism Spectrum Disorders IEP Companion. East Moline, IL: LinguiSystems.
• Sullivan, M., Finelli, J., Marvin, A., Garrett-Mayer, E. Bauman, M., & Landa, R. (2007). Response to joint attention in
toddlers at risk for autism spectrum disorder: A prospective study. Journal of Autism and Developmental Disorders,37, 37-
48.
• Toth, K., Munson, J., Meltzoff, A., & Dawson, G. (2006). Early predictors of communication development in young children
with ASD: Joint attention, imitation and toy play. Journal of Autism and Developmental Disorders, 36, 993-1005.
• Tsai, L. (2001). Taking the Mystery our of Medications in Autism/Asperger’s Syndrome. Arlington, TX: Future Horizons.
• Wetherby, A. & Prizant, B. (2002). Communication & Symbolic Behavior Scales Developmental Profile – Infant-Toddler
Checklist. http://firstwords.fsu.edu