How We Develop a Program Prescription

A Functional Analysis of Behavior and a Developmental Assessment are conducted to determine the child’s skills and developmental capacities.  The analysis is much more comprehensive than traditional ABA Functional Analysis.  Unlike traditional ABA functional analyses, we very much want to know how a child thinks and processes information.  We look at emotion regulation, attachment factors (how the child uses relationships to regulate stress and their environment), and child development of cognitive skills and communication (see above).

Pivotal Responses: We borrow here from the work of Robert and Lynn Koegel, renowned researchers, authors, and developers of Pivotal Response Therapy (PRT), an applied behavior analytic methodology we often use.  They coined the term “pivotal response” to mean a skill that once learned leads to the learning of other skills without direct teaching.  An example of this might be to teach a child to ask, “What’s that?” instead of teaching them words one by one.  The Koegel’s describe pivotal responses as those “…that are central to wide areas of functioning such that improvements will occur across a large number of behaviors.”  Intervening in a pivotal area produces “large collateral improvements in other areas.”

We look for pivotal responses in each domain in which we intervene for an individual child.  Here are just a few examples from the various domains:[12]

Pivotal Emotional Responses

Engaging in intersubjective, experience-sharing interaction with another person Attending to emotional information
Tracking the actions of others Tracking the attention states of others
Embracing rather than avoiding uncertainty and change Accepting challenges.  Responding even when not highly motivated – accepting responsibility without incentives
Following another person’s lead Responding to non-verbal affective (emotional signals) by making changes in behavior
Signaling feeling states to others (emotion-sharing) Responding to others’ emotion gestures with gestures of one’s own (responds to smile with smile).
Emotion-regulation and recuperation from stress Seeking soothing and experience-sharing from others as a response to negative feelings
Determining others’ intent through tracking of their actions Incorporating other’s feelings, consequences to others, etc. in making decisions

Pivotal Social Communication Responses

Engaging in Joint Attention “frames” with others Social referencing (multiple functions)
Understanding the social signals of others Responding to the social signals of others with appropriate changes in behavior
Participating in coordinated “role actions” with others, following another person’s lead Remaining engaged in coordinated social interaction
Forming goals with others and cooperating and coordinating with them to accomplish mutual goals Meshing one’s own goals and agenda with others
Remembering the results of past interactions (in terms of the feelings both partner’s had relative to the experience or interaction) and using the information to guide future behavior Determining the emotional “tone” of a group (e.g., level of excitement, pacing, spatial configuration and attentional direction among members, etc.)

Pivotal Cognitive Responses

Finding patterns in sequences of actions (a tracking skill) Finding similarities between one situation and another.  Noticing differences.
Finding the meaning added between what an individual says and “how they say it.”  (Emotional abstraction). Thinking in terms of theme and variation.  Can add variations to activities without destroying their integrity.
Remembers and can perform actions in sequence Explores objects systematically.  Builds a working knowledge of how objects work.  (Object-related problem solving)
Imagines new course of action and tries them, rather than relying on static forms of problem solving: preset, pre-taught behavioral and linguistic scripts learned by rote and performed with little variation or openness to incoming information Able to shift “mental sets” between one type of information and another.  Moves forward rather than gets stuck.Can think of something else when the familiar elements are still present.
Separates and shifts attention freely back and forth from own actions Follows through on “trains of thought” or action, even with distraction (working memory)

Pivotal Verbal Communication Responses

Using the voice and oro-muscular apparatus; Suck-Swallow–Breathe synchrony Forming sounds (oral-motor praxis)
Mapping unfamiliar words to their correct object reference (a social reference skill) Understanding word and action labels
Understanding simple sentence constructions and (later) how word order changes meaning Using simple sentence structures (with correct morphology and syntax)
Talking and moving at the same time Talking and tracking others’ actions (referencing their attentional states and emotional reactions) at the same time
Managing more than one idea when talking Tracking the change of topics or meaning of words in context

Pivotal Motor Schema

Postural, abdominal control in regards to the movement of limbs Develop skills like balance and trunk control to the level of automaticity, so that the hands can be freed for exploration
Integrating visual and spatial perceptual information with motor actions for reaching, throwing, approaching, etc. Perform basic hand schema for the purpose of exploring objects such as grasping/releasing, twisting/turning, pulling/pushing
Performs actions in sequence (as opposed to single-step circular actions) Able to shift behavioral sets – stop one thing and do another, on a physical action level.
Imitates actions on the level of emulation (action contour only) Imitates actions on the level of imitation (with stylistic elements that convey the “attitude” of the person performing the action)
Inhibits motor actions when necessary Uses forethought to think through actions before executing them
Changes plans internally (mentally) if necessary before acting Thinks of different ways to perform the same action (identification)

Choosing Program Elements

Our philosophy for Program Design has the following guiding principles:

  • No Methodology works for every child in every case
  • No Methodology can “stand alone” as a treatment for any child.  A combination of methods is almost always used.
  • Individual methods have strengths and weaknesses.  Some lend themselves to the teaching of certain skills, whereas for other skills, another method may work better
  • All interventions consist of active and inactive ingredients.  What is active or inactive is highly individual.  Therefore, program elements can be modified by persons with the proper clinical training.
  • All interventions have side-effects, especially if the method is overextended.  Some methods will lead to undue frustration, oppositional behavior, prompt-dependence, or psychological withdrawal if used improperly.
  • All interventions are focused on remediating the core deficits of autism:
    • Attention-shifting and tracking
    • Affective, Intersubjective Reciprocity (Emotion/Experience-sharing)
    • Non-verbal social communication
    • Fluid motor planning
    • Dynamic Intelligence (all of the above)

Developing a Program

Once we complete the assessment and we have determined what the child needs to learn, we then look for the right method to use for the various teaching situations we will devise.  We strongly believe that different methods teach different skills and different children differently!  It takes a very good working knowledge of the advantages and disadvantages of using a particular method to teach a particular skill.  Follow this link for a more extensive comparison and contrast of the various Developmental Therapies.  A brief outline of typical uses of methodologies for early developmental intervention for autism at SCS is as follows:

Therapy Type Strengths Typical Uses
Behavioral Therapies (ABA; Sp. Ed.; Incidental Teaching) Static and instrumental skills; Imitation; repetition where repetition is useful Direct instruction of imitation; supplemental drilling on labels (nouns, verbs, attributes); supplemental drilling of sentence forms
Guided Participation Teaching and (RDI) Parent Training; Dynamic Intelligence; Tracking and Attention-shifting; natural motivation Adult-led teaching of relationship skills in typical household routines, as well as to introduce new play skills.
Child-led Developmental Therapies (FT; Hanen; PRT) Self-initiation; reciprocal communication (FT; Hanen); language skills Specific areas (such as the child’s bedroom) where the child understands that she can lead in play

A daily program may be from 90 minutes to 3 hours, depending on the individual.  It generally consists of separate portions of the session devoted to specific contexts and skills.

Specific Adaptations for Programming

Environments are almost always modified somewhat to provide opportunities for teaching.  When we develop frameworks for teaching, we are careful to estimate, based on a lot of data, the right level of challenge for a child.  If the challenge isn’t enough, we risk stagnation.  If it is too much, the child gets overwhelmed and averse to trying again.  We must be willing to help when needed.

New skills require more support in the way of guidance and perhaps, doing certain things for the child that he cannot do at the moment.  Any type of help or accommodation we offer a child, for something the child needs to be able to do is called a “compensation.”  “Remediation” on the other hand builds skills in deficit areas through teaching.  Some compensations are remediable, and some are not.

Compensations: We look at the compensations presently in use for the child.  Typically, we see that schedules are used to compensate for a child’s sequential memory, scripts are used to teach children “functional communication;” and the child is often hooked on reinforcers.

We then make value judgments as to which compensations are beneficial in the short, intermediate, or long term.  We see the over-reliance upon behavior modification that is unfortunately typical in treatment of children with autism as a detrimental compensation in the long term.  And we will look seriously at other compensations the child could do without if they only learned to be flexible.

Remediations: Remediation teaches skills where deficits previously existed.  Children can indeed learn to be flexible and adaptive, where they no longer need rigid schedules, scripts, static routines to manage their anxiety.  Children also can learn to handle most negative feelings without having to be bribed out of them or “redirected” to something else.

Read this for more on Compensation v. Remediation