EvidenceBased Early Intervention

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Evidence-Based Early Intervention

• Rebecca Landa, Ph.D., CCC-SLP
• Director, Center for Autism and Related Disorders
• Kennedy Krieger Institute
• landa_at_kennedykrieger.org
• Cincinnati, Ohio
• November 7, 2008

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Overview

• I. Thinking about learning
• II. Thinking about how to establish meaning for
  children with ASD
• III. Data from our NIH-funded STAART early
  intervention study for 2-year-olds
• IV. Building conceptualization through event
  representations

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Thinking about learning
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Learning
Autism Poor generalization, problem seeing
beyond the immediate
Autism Sticky attention, focused on restricted
interests, attention to non-salient details
Supported by a host of cognitive affective
processes
Autism self-absorbed, little excites them
especially within social domain
Autism Concrete, poor gist formation, poor
integration of information (islets of information)
Autism Limited exploration, repetitive
behavior, exploration gets fixated on parts
Autism Hard to establish, hard to sustain,
limited spontaneity
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Attention to non-salient detail (local vs global
processing)
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Social Orienting, Response to NV Joint Attention
Cues
Sullivan et al. (2007). Journal of Autism and
Developmental Disorders
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Also

• Difficulty sensing and describing own emotion
• Recognizing emotion in others
• Decoding facial and gesture cues
• Regulating own emotional state

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Self Regulation
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Attention and Motivation
Exploration, Engagement, Meaning, Opportunity
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Attention and Motivation
Exploration, Engagement, Meaning, Opportunity
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Learning is impeded by constraints
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Dealing with Constraints through Scaffolding

• Scaffolding
• Understanding the childs constraints within each
  of the circles
• Providing external supports through simplifying
  the materials and sequence of events
• Task analysis
• Simplifying the options and distance
• Increasing the salience (shake the toy, make it
  brightly colored, reduce distractions)

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Scaffolding
Environmental engineering Limited, sensible
options relevant to tx target Objects that make
sense in context, motivating to engage
with Salience CHEESE, Elmos mouth Model red
or green Opportunity to experience it Lingering
(imitate child topic maintenance) Sequence of
meaningful, related events Gesture cues for
target word
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Dealing with Constraints

• Scaffolding
• Making relationships more obvious
• Visual input augmentation
• Predictability routines and scripts
• Prompting
• Modeling (all or part of the response)
• Intraverbals
• Hints (You can say____)
• Fill in the blank Its a _____
• Questions
• I wonder whose turn it is?

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Instructional Strategies Different ways of
Scaffolding to Optimize Learning

• Discrete trial
• Pivotal Response teaching, Milieu teaching
• Joint Action Routines

• Engineering of treatment space
• Visual input augmentation
• Augmentative communication system (PECS, sign,
  etc.)
• Sensory-based practices

Lots of technical overlap, but variation in
aspects of implementation that could affect
learning in different ways for different children
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Discrete Trial Teaching ABC sequence Discriminiti
ve stimulus Adult-chosen task Repeated
trials Task analyzed Reward unrelated to
behavior Disembedded from context Prompt
hierarchy At table
Pivotal Response Teaching ABC sequence Varied
antecedents Chosen-chosen task Interspersed
targets Simplified activities, comm tempt Natural
reward Embedded in context Prompt hierarchy In
natural context
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More about Learning Insights into what the
child brings to the learning opportunity
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Features of Typical Development

• SOCIAL ENGAGEMENT
• Social responsiveness
• Social initiation
• Social reciprocity (affect, imitation)
• Flexible, adaptive
• COMMUNICATION
• Intentionality and initiative
• Diversity flexibility of form (gesture, sounds,
  words)
• Spontaneity
• Integration with gaze and affect and gesture
• PLAY
• Purposeful, diverse, directed to others, action
  sequences, symbolic

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Videoclips, watch for what the child brings to
the learning opportunity

• What is salient to the child?
• What does child read in another persons face,
  hands?
• What is the evidence for flexibility and
  stability of behavior?

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Seeing these features at 14 months of age
Attention, Motivation, Exploration,
Engagement, Meaning, Opportunity
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Figuring out what to do with novel objects 8
months old
Watch the experimentation Slow Fast Both
hands Single handed
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Incidental learninginvolving another person (10
months old)
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Concept Formation in 14-month-old

• Attention Awareness of objects and others
  actions on objects, attention shifting, joint
  attention for mapping object labels
• Motivation and self-regulation
• Exploration of object (memory, motor planning and
  sequencing skills)
• Engagement (Imitation of novel actions on objects
  (visual reference,)
• Meaning visual referencing skills, joint
  attention for mapping object labels and
  integrating this label during engagement with
  object
• Opportunity

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Connectivity Building concepts

• Creating opportunity through context objects
  and relationships
• Actions on objects
• Diversity of action
• Active comparison between multiple exemplars
• Commonalities across changing exemplars
• Introduction of novelty
• Spontaneous social monitoring
• Your notion of this conceptmine

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Learning in ASD
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Learning Process

• Attention objects, not people
• Motivation low until object of special interest
  was used
• Exploration none at first, grab onto the ring
  stacker
• Engagement watch with scaffolds, then learns to
  wait
• Meaning none at first, then connects the parts
  of the game and the reward
• Opportunity realizes the event sequence, begins
  to take part in it, creates more opportunities
  for himself to learn

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Scaffolds

• Environmental engineering
• Salience (drama)
• Task analysis
• Proximity
• Motivating use objects of interest to child
• Making relationships obvious
• Moves object to get him to visually track it
  (attention to her head)
• Routine, repeat the sequence, build the
  expectation (memory and feeling of the movement)
  and awareness that he could elicit his reward
• Prompts
• Model ah
• Gestural cue hands with palms up as though
  expecting to catch the ring

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How the world sees a child with autism as a
learner
autism
DD
TD
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Compartmentalizing Development
Language
Motor, Sensory
Social, emotional
Cognition, perception
Discrete trials epochs of de-contextualized
events
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Calls for instruction embedded within a
meaningful context, designed to facilitate
integration of developmental systems
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Constructing an Intervention Program to Maximize
Outcomes in Children with ASD
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Elements

• Content of the intervention (curriculum, childs
  specific goals)
• Instructional strategies
• ABA DTT, PRT, Incidental teaching
• Sensory social routines
• Environmental engineering
• Overarching structure
• Theme, Unit, Activities, Materials
• Event representations
• Core targets
• Intensity

Integrate these
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Instruction
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Instructional Content
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When we think about treatment goals for ASD in
EI, we think about

• Getting to speech (match, sort, receptive
  vocabulary ID, vocal and verbal imitation,
  labeling)
• Readiness to learn (compliance, basic skills)
• Imitation
• Play
• Pre-academics (color, shape, counting)
• If enlightened, social cognition and social
  affect

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Lets step back and think about what we are
actually hoping to develop
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Targeting

• Aspects of cognition
• Salience
• Flexible categories
• Conceptualization
• Networked information (multi-modal)
• Gist formation and integration
• Grammar
• Communication social use
• Literacy (minimize hyperlexia by building a
  strong conceptual base)

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Core goals

• Social
• Initiation
• Responsiveness (RJA, response to name, response
  to less and less explicit cues)
• Turn-taking
• Imitation
• Affect range and sharing
• Person recognition
• Emotion recognition - empathy
• Showing, sharing

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Core Goals (I will point these out in videos
later)

• Language
• Categories and Concepts
• Symbols words, gestures, icons, printed words
• Representing a variety of semantic categories
  (location, agency, objects, verbs, pronouns,
  pointing words)
• Word combinations and semantic relations
• Communicative functions
• Play
• Objects that go together
• Functional play
• Symbolic play
• Imaginative play

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Core Goals

• Self regulation
• Self entertainment
• Mood regulation
• Pre-literacy
• Awareness of symbol-meaning relationship
• Rhyming
• Exposure to books
• Interact with the reading process
• Whats a sound, word

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Key principle

• System, connectivity, integration, relatedness
• Continuous flow of interaction and affective
  relatedness
• Creates problem solving and pattern recognition
  preverbal sense of self
• Thinker vs memorizer

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Why? Because this child

• Will have to use the foundation we build now to
• Facilitate implicit learning
• Function in novel situations, deal with
  unpredictability
• Speed processing
• Succeed academically
• Communicate
• Solve problems
• Develop friendships

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Premise

• We are interested in shoring up an integrated
  developmental system (teach basic skills in a
  strategic way to build conceptualization)
• Inseparable cognitive, social, language, motor,
  sensory, perceptual systems
• Help build cognitive structures based on everyday
  events and their actions within those events
• forming event representations
• That is, cognition is shaped and grounded, or
  contextualized by experience

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How do we accomplish this?
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Peer into the childs world

• Objects
• People
• Actions
• Do it again (repetition, predictability,
  surprise)
• Relationships between objects, people
• Engagement
• I can be like you putting it on for size
• Silly

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Achievements Intervention Model

• Overarching goal Build Networks of Meaning
• Using overall structure of themes
• Activity-based learning opportunities and
  building cognitive templates for meaning
  sequences and relationships (Routines)
• Carefully chosen objects affordances for actions
  and relationships

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Our Intervention Model Some key ingredients

• Redundancy and novelty (materials, networked
  activities, core vocabulary and action schema)
• Context
• Ecological validity (makes sense) (multiple
  exposures)
• Use of stories to forecast the event sequence and
  illustrate relationships
• Event representation and daily life (books,
  activities)
• Comfort zone
• Speed How to accelerate learning? Working from
  familiar to novel create predictability
  Interactive initiation and responsivity
  (curriculum, materials, activiities)
• Density/intensity opportunities

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• Themes
• Units
• Activities
• Materials

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Themes

• Overarching frame for teaching new skills
• Concepts
• Actions
• Ideas
• Must be relevant to childs world
• Examples
• About me (self-other, body parts, getting
  dressed)
• The community (shopping, post office, fire
  station)
• Animals (domestic, farm, zoo, aquarium)

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Units

• Next level of specificity for contextualizing the
  concepts to be taught
• Select books for use at this level
• All books in the unit will be related to the
  theme and expose child to core concepts
  (expressed through words, actions, people,
  objects)

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Activities

• Used to engage the child
• Multiple activities per component of schedule
• Permits activity-based learning (honing
  attention, integrating modalities, experience
  leads to knowledge)

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Materials

• Selected based on relevance to story and your
  ability to extend the core concepts
• Selected based on affordances and ability to
  motivate the children

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Objects A Conduit for Building Meaning
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Affordances

• What does the object/person afford?
• The perceptual features and the roles that the
  object/person plays will define these at first.
• Over time, and with increased flexibility, the
  range of affordances and relationships between
  objects (and people and objects) increases.

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Consider features of

• Objects
• Existing motor patterns with and without objects
• Motor patterns in imitated movements

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Routines A conduit for building meaning
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Routines

• Sequence of events that are repeated often
• Become automatic and require little effort to
  perform
• Consist of actions and/or language
• Action and language occur in same combination and
  order each time

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Routines

• The childs encounter with novelty, outside of
  routines, would be unlikely to lead to learning,
  and may elicit unwanted response (drift of
  attention, tantrum)
• Routines constitute Language Acquisition Support
  System (Bruner)
• Routines have acts, act sequences, rules, goals,
  and interchangeable roles

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Within a familiar routine (well engineered)
Attention Eye contact Spontaneous initiation of
communication Spoken language Shared positive
affect Fun, relaxed Now incorporate words/songs/
gestures to connect meaning to story
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Routines form the basis for how to cognitively
represent experience with events
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Event Representations

• Cognitive structures are formed, based on
  experience, that represent events (mind seems
  predisposed to organize cognitions of experience
  in a particular way)
• These representations of everyday experience
  forms the basis for cognitive operations (Grocery
  shopping)
• Over time, representations become more abstract,
  enabling child to perform in novel contexts and
  on novel, abstract tasks with the same
  flexibility as they do in everyday activities.

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Event Representation Example of expanding play
and then language
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How are event representations structured?

• Sequences and relationships, some more temporally
  or causally dependent than others (restaurant
  (formal sit down restaurant vs buffet) vs
  birthday party)
• This event representation translates into mental
  scripts that we can describe, and this is what
  narratives are based on
• Script knowledge enables you to operate on
  automatic pilot and concentrate on the novelty

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Event Representations

• Made up of slots and categories of event
  information such as
• Actors (teachers and students)
• Actions (put belongings in cubby, go to play
  center)
• Props (cubby, picture, toys, bins)
• Allows you to mold the event to accomplish your
  teaching aims

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Building event representation/script

• Cognitive template for events, encoding social
  and communicative/language sequences
• Eases cognitive-linguistic load
• Promotes predictions (anticipation) and
  socially appropriate behavior
• Constrain the possibilities, and hence,
  facilitate appropriate behavior
• Memory aids do this then this or say this, and
  then that will happen

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Every experience is a moving force. Its value
can be judged only on the ground of what it moves
toward and into (Dewey, 1976).
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Evidence-based InterventionandInsights into
systematic integration of intervention ingredients
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KKI EI Study Unique Features

• Early in life
• Developing conceptualization (motivation,
  attention, meaningful context for interpersonal
  synchrony)
• Integration of instructional methods
• Highly explicit teaching to establish prime new
  skills
• More implicit teaching to
• Peers
• Fostering parental responsivity Parent training,
  including focus on wellness and hope, reading
  their children, insights into the dynamic of
  ones behavior on another, skill acquisition
  (creating responsivity a milieu of hopefulness)

Thank you NIMH (STAART Center)
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Unique features possibly active ingredients

• Directly targeting core deficits
• Dosage of response opportunities (intensity)
• Recruitment and retention of motivation,
  attention and engagement
• Building coherence
• Themes and continuity across the various
  activities to establish conceptually-based
  knowledge rather than discrete skills
• Emphasize contextually relevant and socially
  valid application of skills
• Building a network of concepts, through
  multi-modal experiences to enhance concept
  development
• Development as an integrated system

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Possibly Active Ingredients

• Theme-based Intentionally selected stimuli to
  build category and concept formation through
  interactions between perceptual, conceptual,
  linguistic, motor, and social systems
• Careful selection of stimuli Object affordances,
  multiple exemplars, simple to complex (with
  scaffolding to foster processing and engagement)
• Engineered environment highlight salient
  information, promote interaction
• Motivating built on child interests and
  activities

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Possibly Active Ingredients

• Routines-based learning
• Sensory social routines Modulated sensory input,
  motivating
• Other interaction routines Carefully dosed
  redundancy (automaticity) novelty
  predictability
• Active engagement (motor, attention) and
  contingency
• Lingering (give the time for
• response)

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This type of intervention promotes generalization
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Key Developmental Issues

• Affect/motivation
• Initiation
• Flexibility
• Integration
• Attention to salience
• Diversity
• Frequency

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Organizing Instruction

• Systematic infusion of teaching strategies into
  instruction
• Systematic targeting of intervention goals

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Language Targets

• Selecting a core vocabulary
• Because learning of words and expressions depends
  on ones pre-existing concepts, core concepts
  figure importantly in childrens word learning
  (see Bloom, 2000).
• Build a foundation of integrated meaning,
  coherence, flexibility of thought and minimize
  teaching isolated skills

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Opportunity for balance

• Dosing opportunities to develop independence in
  meaningful activity
• Dosing 11 and group instruction

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Parents

• Parent Collaboration Empowerment
• Weekly parent trainings
• Daily communication with parents
• Weekly parent observation day
• Written progress reports
• Communication with community EI providers
• Monthly home visits

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Data Processing

• Rigorous and Multiple Data Collection Systems
• Pre Post-program testing
• Assessment Evaluation Programming System (AEPS)
  assessment at entry, mid, and conclusion of
  program
• On-line data collection by teachers
• Time-sampled behavioral coding via videotapes

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Similarities across treatment conditions

• Dosage 10 hours per week, 6 months duration
• Weekly parent training
• Base Curriculum (except IS targets)
• Class schedule
• Amount of 11 vs group
• Treatment methodology
• Continuum of adult-imposed structure DTT, PRT
• Environmental engineering
• Assessment schedule (pre-tx post-tx 6-month
  follow-up daily and monthly data acquisition
  systems)

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Treatment context

• Center-based
• Combined with home
• Variety of learning opportunities
• Opportunities for initiation and role shifting
• Opportunities for connecting meaning
• Opportunities for social cognition
• Opportunities for social communication
• Opportunities for self-regulation and monitoring
  self (alone and with peers)

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A closer look at the ingredients

• Themes
• Active engagement of children
• Engineered environment
• Scaffolding and continuum of explicit to implicit
  learning opportunities (mixture of methods)
• Motivating
• Routines and predictability
• Event representations
• Core targets/deficits
• Stimuli that afford targeted learning
• Visual input and output augmentation

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Themes Foundation for connecting meaning
through repeated experience linked to context
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Theme FallUnit Pumpkins Activities
SearchingMaterials Pumpkins, bats, containers,
hiding places
Book
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Targeting Core Deficits
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Core Vocabulary and Motor

• Apple
• Pumpkin
• Bat
• Cat
• Look
• Give
• In
• Put
• Big, little

• Reach
• Give
• Point

Allows us to build a generative linguistic
system Noun Verb (agent action) Verb Noun
(action object) Location
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Core Communicative Intents

• Affirm
• Reject
• Show
• Inform
• Greet
• Request
• Call (the attention of)

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Core Social

• Initiation
• Responsivity
• Imitation
• Turn-taking
• Giving
• Role shifting
• Face processing
• Affect sharing
• Self regulation

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Careful Selection of Objects
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Multiple Exemplars
Real, pretend Big, little Hard,
soft Container Beanbag Carve-able Fits in
container
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Object affordances
Plastic pumpkin Look in Put in Swing with
handle Hide behind Hide things in Light it
up Carry-all, storage House Musical instrument
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Routines and event representation
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(No Transcript)
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Schedule

• Free time
• Greeting
• Circle (attendance, prep for book, book with
  related search activities)
• Art
• DTT
• Independent work time
• Generalization and priming
• Event representation prep Social story
• Outside (generalization activities, act out
  event)
• Snack
• Play (wash pumpkins)
• Circle

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Building concept of pumpkins into existing Joint
Action Routines-Greetings
Treatment targets Face processing Intentional
behavior Goal directedness Social
giving/directedness Planning Working memory Joint
attention
Active Ingredients Active engaging with
peers Salient stimuli Theme core
concepts Scaffolds Modeling, showing, input
augmentation (picture)
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Generalizing
Targeting Core Deficits Response to
JA Attention to social Face processing Matching Sa
lience Goal-directed behavior Learning to
point Communicative Intent label, identify
Active ingredients Theme concept Routine Active
engagement of children Scaffolding (positioning,
modeling, physical guidance) Salient stimuli
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Activities
Look! Pumpkin!! Johnny, Get
pumpkin Opportunity for child to ask Whats
that? _________________ Once the bat is out,
play routine (sensory Whoosh) is created. Then
each child whooshes peer next to them,
experiencing the role of initiator and
receiver Prepped for finding the bat that will
appear in the story.
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More experience with pumpkins
Gaining hands-on experience with pumpkins Small v
big Containment (in) Action experience
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Teaching event representations through literacy
Attention Language RJA Gesture Consciousness of
self Category formation
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Notice the information flow topic maintenance,
relevance, meaning
Is that a pumpkin? No (gesture denying the
false assumption) What is it? Its a cat Notion
of surprise Open and find (object permanence) Get
the cat Match (discrimination, category formation)
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Connecting book to environment
Extending the concept beyond the book Initiating
and following JA Communicative intents Locatives G
esture Emotion context Search and find
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By now, exposure to Bat in pumpkin Whats
that? Whoosh game with bat Bye Bats Bat in
story Wheres bat? IJA to shutters on wall
open them and bat is inside. Get bat label,
experience, go away (disappearance) See bat in
book once more
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Infusing thematic principles throughout all
activitiesArt
Purposive behavior Visuo-spatial Face
organization Use of environmental cues to
learn (implicit learning)
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Sensory-based gross motor and shared affect
activity
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Building the concept at various discriminative
levels (DTT)
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Table Time
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Transferring cognitive concepts through
play-Object Permanence
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Preparing for participation in an everyday
activity using an event representation
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Were going to the pumpkin patch
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First, we will go for a wagon ride
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I will get in the wagon
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Incorporating experiences on the concept object,
(protoverbs) pumpkin down
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Outside
RJA Planful search Goal oriented
behavior IJA Sequence of behavior
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Actions on Objects in PlaySequencing, diversity
of actions
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Final conceptual formation Five Little
Pumpkins
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Summary and Conclusions
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Provocative Questions

• Is this early alteration in the social mind,
  integrated with cognitive and language growth,
  going to fundamentally alter learning processes
  in toddlers with ASD?
• Is there a critical event in development that
  triggers a shift in trajectory of development?
• What type of stimulation can awaken a
  developmental shift in severely mentally retarded
  children, or children whose attention,
  perceptual, and sensory systems are severely
  impaired?