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Special Education Verification and Effective Instructional Practices for Children with Autism Spectrum Disorders (ASD)

Nebraska Special Education Advisory Council


through the work of the

Presented by the

Ad Hoc Committee on Autism Spectrum Disorders


May 2000

Nebraska Department of Education


State Board of Education

Kimberly J. Peterson District 1 Ann Mactier District 2 Bev Peterson District 3 Rick C. Savage District 4 Stephen A. Scherr District 5 Fred Meyer District 6 Kathy Wilmot District 7 Kathryn Piller

District 8

Special Education Verification and Effective Instructional Practices for Children with Autism Spectrum Disorders (ASD)
Presented by Special Education Advisory Council Ad Hoc Committee On

Autism Spectrum Disorders


Edited by

Linda Schafer Nebraska Department of Education Special Populations Office

May 2000

Published by

Nebraska Department of Education Special Populations Office 301 Centennial Mall South Lincoln, NE 68509-4987 402/ 471-2471
Funded by

Nebraska Department of Education under IDEA, Part B and Part C Grant # 4027A980079 and Grant # H181A980033

Acknowledgments
The Special Populations Office and the Nebraska Special Education Advisory Council extend appreciation to the ad hoc committee members and to the agencies who provided the release time for these individuals during the development of this document. This document became a reality because of the dedicated committee and individual efforts of . . . Dr. Keith Allen, Child Psychologist, Monroe Meyer Institute Pam Brown, School Psychologist, NEAT Center Jo Haugland, Preschool Coordinator, ESU #16 Dr. Akhtar Niazi, Pediatrician and Parent Sandy Peterson, Assistant Director of Special Education, ESU #3 Deb Sabers, School Psychologist, Papillion LaVista Public Schools Linda Schafer, Coordinator, Special Populations Office, Nebraska Department of Education Dr. Ellin Siegel, Faculty, University of Nebraska at Lincoln Dr. Kelly Wanzenried, Special Services Coordinator, Westside Community Schools Debra Weston, Attorney and Parent Pam Wilson, Nebraska Department of Health and Human Services Jane Wolfe, Early Childhood Special Educator, Lincoln Public Schools

Also involved in development and review were


Rhonda Bojanski, Parent Kay Stammers, Parent

Brad Thompson, Parent

Special Education Verification and Effective Instructional Practices for Children with Autism Spectrum Disorder (ASD)
Table of Contents
Autism Spectrum Disorders (ASD)................................................................1 Definition...................................................................................................1 Comments and Considerations................................................................2 Proposed Criterion, Features, and Possible Profiles.....................................5 Criterion #1 .........................................................................................6 Criterion #2 .........................................................................................8 Criterion #3 ....................................................................................... 10 Criterion #4 ....................................................................................... 12 Associated Indicators.................................................................................... 16 Considerations for Assessment of Children Who May Have an Autism Spectrum Disorder............................................................................ 18 Concepts of Assessment................................................................... 18 Strategies for Assessment................................................................. 22 Direct Observation Assessment Checklist: Autism Spectrum Disorders . 28 Checklist Protocol ............................................................................. 30 Principals of Effective Instructional Practice for Children with Autism Spectrum Disorders .......................................................................... 34 Recommended Characteristics of Services ..................................... 35 Summary of Several Approaches to Intervention Programming.............. 39 Developmental Concepts ................................................................. 40 Behavioral Approaches .......................................................................... 41 Applied Behavior Analysis .............................................................. 41 Pivotal Response Training ............................................................... 42 Discrete Trial Training...................................................................... 42 Functional Communication Training.............................................. 43

Lovaas Training................................................................................ 44 Biomedical............................................................................................... 45 Biological/Medical Treatments....................................................... 45 Educational ............................................................................................. 46 Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) .......................................... 46 Communication Strategies .............................................................. 47 Natural Language Paradigm........................................................... 47 Picture Exchange Communication System .................................... 48 Social Stories ..................................................................................... 48 Neurosensory.......................................................................................... 49 Sensorimotor Therapies................................................................... 49 Psychotherapy ........................................................................................ 50

Appendix A: Adapting the Environment ................................................... 51 Appendix B: Functional Activities .............................................................. 52 Appendix C: Approaches Chart .................................................................. 53 Appendix D: Proposed 92 NAC 51 Language............................................ 54 Appendix E: Annotated Bibliography......................................................... 58 Appendix F: References................................................................................ 75

Autism Spectrum Disorders (ASD)


Definition
ASD is a lifelong neurodevelopmental disability, a behaviorally defined syndrome that is recognized

by the manifestation of behavioral characteristics across multiple areas of functioning. Characteristics are observed, to varying degrees, in social relationships, communicative competence, pattern and range of interests, and sensory responsiveness. These characteristics are generally evident during the child early years, and must adversely s affect educational performance. The definition of ASD has been written sufficiently broad to encompass children who exhibit a range of characteristics related to ASD. This includes Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. Children with mental retardation or significant behavior disorders are not automatically excluded since, in many cases, these conditions coexist with ASD.

Autism Spectrum Disorders

Autistic Disorder

Rett s Disorder

Childhood Disintegrative Disorder

Asperger s Disorder

Pervasive Developmental Disorder Not Otherwise Specified PDDNOS

Many professionals define ASD and pervasive developmental disorder (PDD) based on a diagnostic manual printed by the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV. According to the DSM-IV, the term PDD is not a specific diagnosis, but an umbrella term under which the following specific diagnoses are defined: Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (PDD:NOS). They all share common features to varying degrees, but are clinically distinct and may be separately diagnosed. It is critical to understand what constitutes autism spectrum disorder (ASD) and what

Comments and Considerations

does not. ASD is a lifelong neurological disorder that affects the functioning of the brain with resultant combinations of distinct behaviors. There are definitions that describe symptoms and characteristics that comprise a diagnosis (medical) or verification (educational). ASD is defined and assessed through specific behavioral features. Students with ASD present unique neurological and behavioral characteristics. In addition, there is the spectrum of involvement within the disability. In this document the range of categories is referred to as ASD in order to encompass Rett Disorder, Child Disintegrative s Disorder, Asperger Disorder, and Pervasive Developmental Disorder s Not Otherwise Specified. For as long as autism has been described there has been debate on what constitutes "true" autism. Over the past 15 years, however, it has become clearer that ASD is a syndrome, not a disease in the traditional sense of the word. As a syndrome, characteristics which manifest in ASD vary on a continuum of severity. Core features must always be observed but the range of

associated features is wide. (Powers 1992). The degrees to which characteristics of ASD are observable vary from one child to the next. Characteristics may be mild or severe and may appear differently in each individual. Some characteristics may disappear over time and new ones may arise. While similar traits, mannerisms and behavioral characteristics may be present in individuals with ASD, no two individuals with ASD will exhibit exactly the same profile of strengths and needs. The definition in this document (page 7) reflects an educational diagnostic description of ASD. It clarifies the prior definition used in 92 NAC 51 and Autism Verification Criteria, A Technical Assistance Document on Autism. It does not enlarge or include any additional characteristics or manifestations of autism. In this document, the definition of, criterion, and procedures for identification of children with ASD and the provision of individualized services within special education rules and regulation are based on an educational model rather than using the medical classification system of the American Psychiatric Association in the DSM-IV (American Psychiatric Association, 1994). An educational model was chosen because the state of Nebraska is committed to improving educational possibilities for students with ASD. It is critical that educators appropriately verify children with ASD and educate professionals and parents about the learning characteristics of this disorder. Most importantly, whether an educational or medical model is used, the student's education and services should be the same, based upon individual strengths and needs. ASD is not a rare disorder. Prevalence estimates for the full spectrum of ASD may be more than 2 per 1000. It is more common than Down syndrome, childhood cancer or Fragile X syndrome. (Bristol & Cohen, 1996) Although ASD is evaluated by observing behavioral

characteristics, it is not a behavioral disorder, emotional disorder, conduct disorder or mental illness. People with ASD may share some characteristics with those who have severe emotional disturbances, behavior disorder or those with specific learning disabilities. However, there are distinct differences in term of characteristics, service needs and future expectations. These differences have significant impact on decisions relating to services, interventions and placements. ASD may occur in conjunction with other disabilities mental retardation, epilepsy, hearing impairments, cerebral palsy, anxiety disorders, depression or organic brain disorders. Although once thought to be psychogenic or psychologically caused, no known factors in the psychological environment cause ASD. ASD occurs in children of every nationality, race, and socioeconomic level. Children with ASD have complex and often challenging educational needs. To meet those needs effectively, school districts need to include professionals with experience and expertise in ASD when planning and implementing educational programs for these children. It is often a challenge for school districts to locate and maintain staff who have the critical expertise that is needed to develop and implement effective programs for individuals with such a wide range of needs. The following materials are intended to provide a better understanding of current Rule 51 language as well as the proposed language for the revision of Rule 51 verification of children having ASD and to provide resources for additional assistance. Terminology in the revised definition are used to assist families and educators to accurately verify children with ASD by describing the characteristics with greater distinctness and specificity. See Appendix D for the proposed Rule 51 language changes.

Proposed Criterion, Features, And Possible Profiles


The verification criteria required in the proposed language for 92 NAC 51 for ASD are divided into four (4) major parts. The proposed language can be found in Appendix D of this document. Criterion #1 Atypical development of social competence Criterion #2 Atypical development of communicative competence Criterion #3 Atypical range of interests and patterns of behaviors Criterion #4 Unusual or inconsistent responses to sensory stimuli The criteria will be presented on the following pages along with typical features of that criteria and possible profiles of children exhibiting the features. It is important to remember that ASD is a spectrum disorder, meaning the features and characteristics of ASD can present themselves in a wide variety of combinations, from mild to severe. Although ASD is defined by a certain set of behaviors, children may exhibit any combination of the behaviors in any degree of severity. Two children, each with a diagnosis of ASD, can act very differently from one another. In order to be verified as a student with ASD, an individual must display an impairment(s) within each criterion. For each criterion there are sample Features and Possible Profiles. Children do not have to exhibit impairments within the listed Features and Profiles. These are included for the purpose of describing and giving examples. The criteria presented here, however, are intended to

encompass this entire class of related neuro-developmental disorders. Some children with ASD will evidence advanced and even precocious development in nonimpaired domains, but this is not a reliable defining feature of ASD. In addition, these differences in rate and sequence may not be apparent until well after a child has been exposed to an educational environment. Thus, the criteria currently found in Rule 51 describing disturbances in developmental rates and sequence are recommended for removal. Refer to Appendix D to review the proposed Rule 51 revisions. The criteria currently found in 92 NAC 51 describes disturbances of cognitive processes and relies on the observer ability s to detect cognitive constructs rather than behavioral characteristics, which are the hallmarks and necessary features of any definition of a syndrome. In addition, some of the constructs (e.g., perseverative thinking) could be assigned behavioral concomitants (e.g., patterns of behavior) that were better included under other criteria (i.e., criterion #3 above). As a result, the cognitive process criteria were removed in this document.

Criterion #1
ATYPICAL DEVELOPMENT OF SOCIAL COMPETENCE. The child displays difficulties in social relationships. The child often has difficulty establishing and maintaining reciprocal relationships with others. In young children, characteristics most frequently observed include impaired nonverbal/gestures, little or no eye contact, little or no joint attention, and rare initiation of social interactions or enjoyment of social games. In older children this may be evidenced through few quality peer relationships and a gener al lack of awareness of social conventions.

This criterion, previously included as part of disturbance in relating to people, events, and objects, in Rule 51 is now recommended as a separate characteristic. This characteristic has long been considered one of the most reliable characteristics of ASD and warrants inclusion as a unique and distinct class of characteristics.

Features
Students may demonstrate impairments in the use of nonverbal communication or gestures: smiling response; stranger anxiety; anticipatory response to gestures; impairments ranging from mild to severe in the use of eye contact, and facial responsiveness. Students may fail to look at an object that is pointed at or rarely point at objects themselves with the intent of directing the attention of a peer or adult toward the object. Students may lack awareness of components of true social interactions; i.e., nonverbal and verbal communication, empathy, reciprocity, or social negotiation. Students may demonstrate impairments in cooperative and or reciprocal play involving games such as peek-a-boo, patty-cake, or waving bye-bye. Cooperative play, if developed, may be delayed and may be superficial, immature, and may occur only in response to strong social cues and/or direct instruction. Students may prefer to be alone and show little interest in other children. They may also fail to develop relationships with significant caretakers. While some reject interactions, other individuals with ASD may occasionally seek social interactions, but their attempts may be ineffective, inappropriate, and thus unsuccessful. They may express loneliness, but have difficulties relating to others.

There may be giggling, laughing, or crying without identifiable reasons.

Possible Profiles
KA will quietly walk the perimeter of a room, never looking at others and actively resisting attempts to engage him in eye contact. DW shows no interest in playing with peers or siblings when they are in the same room, preferring instead to spin the wheels in a small toy train. KW will initiate interactions with peers, but he averts his gaze, introduces conversation that is only tangentially related to the topic of his peers, and he becomes hysterical when the group does not follow rules he makes up for social games. JE will play alone on the playground, even when participation is actively recruited by peers. She has a generally blank expression, but will occasionally giggle out loud.

Criterion #2
DISTURBANCE OF COMMUNICATION. The child exhibits a qualitative impairment in communication. This may include echolalia, mechanical or stilted speech, little response to language, pronoun reversals, and difficulty expressing emotions. There may be a complete absence of spoken language. Even when verbal language is age-appropriate, oddities may be observed in the communicative process. This criterion has been revised and clarified to include those children who may exhibit behavior that is at the higher functioning end of the ASD spectrum disorders (i.e., Asperger s).

Features
The student may display loss of speech, delayed onset of speech, immature or disordered syntax, and/or articulation. Voice quality may be flat or mechanical with little variation of pitch and volume. Students may have difficulty using language in fluent, interactive communication. Students may have difficulty initiating verbal interactions to express their feelings of confusion, frustration, and anger. Use of language may be concrete and literal. The child may be confused by words and expressions that depend on the context for meaning, such as space and time words (i.e., here/there/later), homonyms (i.e., blue/blew), pronouns, jokes, sarcasm, and figurative language. Nonverbal communication: There may be absent or delayed development of appropriate gestures, disassoc iation of gestures from language, and failure to understand symbolic meaning of gestures. The student may use formal or stilted speech to communicate. The student may call everyone by their whole name, including people they know well. Higher level awkward vocabulary may be used instead of more comfortable slang or language children more often display.

Possible Profiles
O.T. uses another person's hand as a tool to get an object for him rather than reaching for the object himself. C.W. has had a vocabulary of approximately 20 words for over two years. No new growth in vocabulary has taken

place since, as opposed to children who continue to add vocabulary at a fast pace. P.Q. demonstrates echolalic speech -- repeats words, phrases, and sentences with little or no meaning. O.Z. perseverates on phrases heard at another time; i.e., TV programs, radio jingles, product logos. D.P. is verbal and uses three to four word phrases. He communicates more in-depth thoughts by drawing a sequence of pictures to depict his thoughts.

K.F. always refers to himself in the third person. Criterion #3


Atypical range of interests and patterns of behavior The child displays a narrow, encompassing preoccupation with objects, parts of objects, sensations, rituals, or routines. The child may display stereotyped or repetitive body movements. The focus or intensity of these interests and patterns is abnormal and the child may display marked distress over changes, disruption, or interference with these interests and patterns of behavior. Note: The characteristics and features described here were previously included within other criteria. Criterion 3 describes the behavior demonstrated by narrowed focus, limited interest, and encompassing preoccupation, which leads to a reliable collection of common characteristics.

Features
Students may use objects, in idiosyncratic, stereotypic, and/or perseverative ways. Interference with this use of objects may result in expressions of discomfort and/or

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panic. There may be a particular awareness of the sequence of events and disruption of this sequence may result in expressions of discomfort and/or panic. They may have developed complex routines or rituals and exhibit distress if unable to carry them out. This may include lining up objects, needing to have his/her desk in the same position, and following rigid routines for tasks which must be performed, like bed time, brushing teeth, and getting dressed. Self-injurious behaviors, such as hair pulling and hitting/biting parts of the body, may be present. Stereotypic and repetitive movements of limbs or the entire body may occur. Students may demonstrate perseverative thinking and be preoccupied with certain sounds, words, phrases, ideas, or items, and have difficulty switching the focus of attention. Students may learn a skill in one setting but have difficulty generalizing the skill to new settings and situations. Students may have an excellent memory for visual detail, facts, or rote lists but be unable to recall other information. Students may focus on small details and demonstrate little awareness of critical elements or information.

Possible Profiles
G.B. insists on placing alphabet blocks in exact order before complying with teacher request to start an unrelated task. H.B. insists that action cards in a game are in the exact same order each time the game is started. P.N. always aligns Legos in the same color sequence -- red, blue, yellow, red, blue, yellow -- and refuses to change the

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sequence. M.T. always places all farm animals in a line each time he plays with the farm rather than playing with the pieces in a conventional manner. O.R. becomes agitated and at times physically aggressive when the daily routine is broken, or during times of change or transition. This behavior is decreased if he is given information prior to the event.

Criterion #4
DISTURBANCE OF RESPONSES TO SENSORY STIMULI. The child exhibits atypical, unusual, or repetitive responses to sensory stimuli. The child may exhibit these atypical responses to any or all of the following sensory modalities: sight, hearing, smell, taste, touch, balance, body awareness, and pain. The intensity of the response to these stimuli can range from unusually high levels to unusually low levels.

Features
Sight: There may be close scrutiny of visual details staring; prolonged regarding of hands or objects; attention to changing levels of lighting; preoccupation with spinning objects. Hearing: There may be close attention to self-induced sounds non-response or over-response to varying levels of sounds. Smell and Taste: There may be repetitive sniffing, specific food preferences, and licking of inedible objects. Touch: There may be atypical responses to being physically touched, hugged or squeezed; atypical response to extreme

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temperatures; prolonged rubbing of surfaces; strong negative or positive reaction to specific textures of foods. Balance: There may be excessive whirling, spinning, or rocking. Body position/awareness: There may be posturing, darting/lunging movements, hand flapping, gesticulations, and grimaces, or poorly coordinated gait or trunk movements. Pain: An over or under response to conditions that would or should cause pain, discomfort or irritation.

Possible Profiles - Sight


B.J. is sensitive to lights in the classroom and will hide his head under his own arm. B.O. is unable to continue classroom work without covering his eyes with his hand. J.J. remembers exact details and locations of objects in classrooms and can locate them immediately months later after having visited that site only once.

Possible Profiles-Hearing
O.W. appears to have a significant hearing impairment but runs to the television immediately when he hears a commercial jingle. C.H. has no difference in hearing ability but cannot tolerate fire drill alarms in school. P.B. does well in school but is disturbed and distracted by the buzzing of fluorescent lighting.

Possible Profiles - Smell


M.D. demonstrates inappropriate social smelling goes

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immediately to person entering a room to smell his/her arm, hand, or other body parts. B.P. sniffs all materials before working with them; i.e., paper, books, toys, etc.

Possible Profiles - Touch


L.M. demonstrates excessive self-stimulating, stereotypical movements rocking, lunging, hand flapping, twirling, hand wringing in excess. J.Z. requests to be allowed to squeeze himself into his school locker as a reward for work completed. C.D. may seek physical contact with others and has been known to take the teacher's hand and request "rub head" when physical contact is not otherwise there. D.M. refuses to wear anything but long-sleeved shirts and long pants. J.D. avoids art activities involving hands, like finger painting or molding clay. L.S. is extremely sensitive to light touch from others and will recoil, cower, or withdraw. However she will tolerate and even enjoys firm and consistent direct pressure/touch.

Possible Profiles -Balance


F.R. cannot maintain a standing balance with her eyes closed.

Possible Profiles - Body


M.C. must be told to raise her arms to waist level before a ball is tossed to her or she cannot catch the ball. K.J. has great difficulty writing without using weighted

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wrist cuffs.

Possible Profiles-Pain
D.D. uses language, reads and writes very well but rarely indicates when he is ill or has pain. T.M. burned his arm on a hot lamp and gave no indication that he had any pain and completed his work.

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Associated Indicators
The following indicators may be observed in children with ASD, but are not observed with sufficient reliability to be considered verification features. They may be helpful to observe and consider in the verification process and in the planning of effective instruction.

Features
Mental retardation may be present, commonly in the moderate range of intellectual impairment. There may be differences in the rate of development of cognitive skills, and the profile of skill development may be uneven or out of sequence. Behavioral characteristics may include hyperactivity, short attention span, impulsiveness and temper tantrums, emotional outbursts, verbal/physical aggressiveness or self injurious behaviors. Difficulties with judgment may be present, as evidenced by apparent lack of fear in response to real dangers or excess ive fearfulness in response to harmless objects or situations. Difficulties with abstract thinking or reasoning may be present.

Possible Profiles
L.A. has low/normal intelligence, yet demonstrates wide gaps in his ability to generalize common sense information; i.e., he is academically competitive on age level yet cannot open a car door, has no comprehension of drowning/dying in response to a story, is unable to walk into a store and

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purchase a product, etc. K.R. can sit down after having once seen the credits for a movie and type all the names of the people mentioned. The titles and credits appear to have no meaning for the student -- only the names. Z.L. who entered school at age five (5) knew how to read without having been taught and was able to write one to three word phrases to communicate needs and thoughts, yet demonstrated no ability to use the information in a typical fashion. M.P. can match words, pictures, symbols, or objects with speed and accuracy, but is unable to move to a higher cognitive level; i.e., after matching picture cards for a ball, she is unable to locate the object. Z.A. appears to be unaware of cars and the dangers they impose, as he neither looks for cars in his path nor checks for oncoming cars when crossing a street. R.H. has been caught numerous times walking the narrow ledge of a high retaining wall, he shows no evidence of being aware of the dangers. R.S. has low/average intelligence and performs academically at age level, but cannot problem-solve common daily life situations (e.g., can not independently make purchase decisions).

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Considerations for Assessment of Children Who May Have an Autism Spectrum Disorder
Assessment is a process that is undertaken to verify a special education disability and to facilitate quality decision-making in developing individual family service plans (IFSP) or individualized education plans (IEP). A thorough assessment provides information that can be used to accomplish three different but important aspects of an educational program: 1. Verification and subsequent special education eligibility decision; 2. Foundation for developing and designing realistic instructional objectives and interventions; and 3. Establishing present levels of performance to measure progress. Assessment procedures that lead to accurate ve rification and effective intervention and evaluation are considered best practices (Hayes, Barret, and Nelson, 1987; Shapiro, 1997). Notice that verification and assessment are not synonymous. Verification refers to determining if features demonstrated by a child are congruent with the NDE verification criteria in Rule 51. Those features are identified through assessment procedures. Verification is one goal that can be accomplished through assessment. Assessment also provides detailed information about the specific strengths and needs of an individual. (Marcus & Stone, 1993).

Concepts of Assessment

To design successful educational experiences for students with ASD, the assessment must generate information about the strengths and needs of the

individual student as well as strengths and needs of the environmental resources needed to support the student. A competency model is

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based upon the concept that the education programs for a student with ASD describes what the student needs to work on to achieve the outcome of functioning as a competent person in society. Being competent does not necessarily mean being completely independent, but it does require that a person be a contributing member of a community. This requires the ability to interact successfully with other people and to succeed in activities that are valued in the community. This ASD competency model suggests that there are two major factors that influence student success at becoming competent: risk factors and protective factors. Risk factors are those aspects about the student and the environment that are needs or obstacles for the student. Protective factors are those aspects of the student and environment that are strengths and serve to assist the student in overcoming challenges and allow the student to be successful. The model predicts that the student can be successful when the protective factors (strengths) counterbalance the risk factors (needs). A thorough assessment must include strategies for measuring the strengths and needs within a variety of areas described in the following. Protective and Risk Factor Domains 1. Social Competence: Children with ASD have social interactions characterized by both quantitative and qualitative impairments. Look for and ask about difficulty with: learning social interactions in an unstructured fashion; initiating social behavior without supports; sustaining social interactions in a reciprocal manner; joint perspective taking and joint attention; and turn-taking 2. . Communication Functioning: Children with ASD have

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impairments in their ability to understand what is heard and to communicate what is known. Look for and ask about difficulty with: delayed use of gestures; use of echolalia; oddities in volume, cadence, pitch; failure to generalize word meanings; failure to understand questions; and rarely asks wh questions. 3. Cognitive Functioning: Children with ASD have thinking processes that are characterized by over selective memory for details along with deficits in processing information. Look for and ask about: interest in parts of objects (e.g., wheels); negative reaction to change (e.g., attempts to control change through ritual); preoccupation with topics or intense interest in details; stereotypic movements (e.g., rocking, flapping, twirling); and delayed intellectual development.
4.

Sensory Regulation: Children with ASD may experience sensitivity in areas of the senses which interfere with their ability to participate in learning. Look for and ask about difficulty with: not wanting to touch certain objects/textures; unusual response to sounds; preoccupation with tasting and smelling objects; preoccupation with visual stimulation; and distraction by sensory aspects (e.g., sounds, lights) of

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surrounding environment.
5.

Environmental Influence: Children with ASD must experience a variety of people, places and things with which the student must interact to be successful. Because the nature of ASD inhibits adaptability and generalization across settings, strengths and needs must be considered in each environment in which learning is to take place. Look for and ask about: demands that are beyond the capabilities of the student (e.g., sitting too long, expecting performance in large group, waiting is required); overwhelming stimuli (e.g., crowds, noise, and pace), with no escape permitted; lack of direct teaching of social interaction skills; use of punitive rather than positive behavior strategies; lack of consistency within a program and across people and settings; and lack of collaboration between home, school, and other team members.

Physical Functioning/Motor Skills: This includes impairments in motor planning, poor muscle tone, spatial skills, and general understanding of body-inspace. Look for and ask about difficulty with: moving around a room; holding a pencil or crayon; and toe walking.

7.

Play/Leisure Skills: This includes uses of free time and play skills. Look for and ask about:

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inappropriate toy play (e.g., banging toys, lining toys up); increased stereotypy during free time; and lack of imaginative/symbolic play. 8. Educational/Academic Skills: This includes basic school performance. Look for and ask about: functional application of facts; basic knowledge of academic facts; ability to work independently; and ability to follow tasks in sequence. 9. Self-help/Independent-living Skills: This includes a variety of adaptive behaviors involved in daily living. Look for and ask about skills related to: dressing; feeding; toileting; safety; and personal hygiene.
10.

General/Vocational Behavior: This includes general school and/or work behaviors. Look for and ask about: following directions; working independently or with support; following simple rules; and tantrums in response to work or school demands.

Strategies for Assessment

There are three principle methods for gathering information across each of the protective and

risk factor domains (Shriver, Allen & Mathews, 1999). Since assessment is dependent upon the observance of collections or patterns of behavior within these domains, observation of student behavior and

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the educational environment plays a key role in the assessment process. Since observation of all domains is rarely possible, verbal report (interview) from home and/or school personnel is an acceptable means for gathering needed information. Finally, although there are no direct tests of ASD, direct interaction with the individual with ASD is an important means of gathering information about specific types of functioning within different domains. As with other clinically diagnosed syndromes the most thorough and accurate assessment of ASD will involve data from a variety of sources collected using a variety of measures. Note that the specific measures that are described in the following three sections are intended only as examples. It is not the purpose of this document to provide an exhaustive list of all possible measures that can be used in assessing ASD. Direct Behavior Observations Direct observation of each of the protective and risk factor domains should make up the primary source of information in the assessment of ASD. When classroom observations are not possible, or when the child is pre-school age or not yet placed in a classroom, then parent-child interactions should be observed, preferably in the natural (i.e., home) environment. To assist in the assessment, published behavior observation scales designed for use with children with ASD can be used (Krug et. al., 1979; Schopler et. al., 1990). These include the Autism Screening Instrument for Educational Planning (Krug, Arick, & Almond, 1993) and the Autism Diagnostic Observation Schedule (Lord, Rutter, Goode, Heemsbergen, Jordan, Mawhood, Schopler, 1989). To assist school personnel with structuring observations, the recently published Direct Observation Assessment Checklist beginning on page 27 (Shriver, Allen, & Mathews, 1999) can be used. This checklist prompts the observer to monitor behaviors within each of the domains

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described above, and will integrate behavioral observations across settings, activities, and people. The Behavior Observation Checklist is not a standardized instrument, but school personnel have provided anecdotal reports that suggest the checklist is valuable in drawing attention to domains that are important for educational programming and evaluation of programming as well as for verification. Probably the most widely used observational protocol for a child with ASD is the Childhood Autism Rating Scale (CARS) (Schopler, Reichler, Renner, 1988). The CARS is composed of 15 scales on which a child behavior is rated from within normal limits (1) to s severely abnormal (4). A total score is computed. The CARS has an extensive history of development for use within the Treatment and Education of Autistic and related Communication handicapped CHildren (TEACCH) program. The CARS is probably best used as a screening measure since the normative comparison group is based solely on children referred to the TEACCH program in North Carolina.
Because children with autism spectrum disorders have significantly impaired ranges of behaviors and interests, it is often difficult to identify reinforcers to use in treatment and educational programming. Direct observation of a child preferred activities during "free time" should assist s in identifying potential reinforcers. Direct presentation of different items or activities may also assist in identifying potential reinforcers by observing the child response (e.g., child smiles, reaches for object, pushes s object away, cries). Finally, direct observation of behavior should allow the assessor to develop hypotheses about the purpose (function) of challenging behavior. This can be accomplished by considering the apparent correlation between target behaviors and the events that occur just before and just after a target behavior. Knowing the purpose of problem or target behaviors will assist in designing effective educational programming.

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Direct Verbal Report Parents or caregivers are an excellent source for information regarding behaviors within each of the protective and risk factor domains. In addition, because age of onset is an important consideration in the verification of ASD, developmental history should be obtained. There are several standardized behavior rating forms available for use in assessing and diagnosing ASD such as the Autism Behavior Checklist and the Gilliam Autism Rating Scale. These typically involve asking parents to provide direct verbal report of behaviors that are characteristic of ASD. Because of the relatively low incidence of ASD, the normative comparison groups for most behavior rating instruments are relatively small and none of the behavior rating forms have adequate reliability or validity to use independently in the verification of ASD. As a result, both instruments function best as screening devices. It is most effective to use several behavior rating forms in combination with direct observations. In addition, more information regarding the presentation of behaviors across settings will be provided if different raters (i.e., mother, daycare provider, and teacher) complete each of the forms. A standardized measure of adaptive behavior such as the Vineland Adaptive Behavior Scales or the AAMR Adaptive Behavior Scales) can also be used to quantify impairments in daily adaptive functioning. While this information may assist in diagnosing mental retardation, these measures provide no information about the qualitative impairments that are characteristic of ASD.

Direct Testing There is no direct test for ASD. ASD is determined by combining information from as many different sources as possible. Cognitive assessment is the most common type of direct testing

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available, but it is not necessary for the determination of a verification of ASD. In fact the validity of any standardized cognitive assessment with a child with ASD is questionable given that standardized intellectual assessments require, as a prerequisite, the very response repertoire that is missing in children with ASD (i.e., functional expressive language and reciprocal social interactions). Intellectual assessment may be of value in ruling out mental retardation, but only if a child has the skills to communicate with an examiner, attend to relevant test materials, and can engage in appropriate test behavior. Note, however, that the results of a standardized intellectual assessment may offer little assistance in making educational programming decisions. Finally, there is no evidence that children with ASD exhibit unique profile patterns on intelligence measures such as the Wechsler Intelligence Scales for Children - III. Several norm-referenced instruments do exist for assessing disturbances in developmental rates and sequence. The Bayley Scales of Infant Development are particularly valuable in this regard, especially with very young children. But caution must be used to avoid using the instrument as a measure of intelligence or cognitive development. In addition, for the same reason cited above, it should not be used with older children, where the items place a heavy emphasis on emerging language skills. There are also multiple instruments for direct testing of communication understanding and use of language and nonverbal abilities. The general measures of broad language abilities may be the most useful because they do not penalize the children for deficits in any specific response mode. These include the Communication and Symbolic Behavior Scales, the Clinical Evaluation of Language Fundamentals - 3, the Preschool Language Scale-3. And the Oral and Written Language Scales, etc. An assessment of communication should include analysis of a sample of the individual spontaneous s

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communication (speech, language, gesture, picture - symbol use, etc.) with both adults and peers. The Psychoeducational Profile and the Autism Screening Instrument for Educational Planning are also useful instruments for direct testing of children who are thought to have ASD. Both measures provide global information about social functioning, communication skills, and behavioral variability. They are not, however, diagnostic tools by themselves. They are most useful for generating practical information to use when developing educational programming.

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Direct Observation Assessment Checklist: Autism Spectrum Disorders


The following checklist is designed to assist with conducting a thorough assessment of potential autism spectrum disorders (Shriver, Allen, & Mathews, 1999). It is important to remember that there is no single tool, instrument, or strategy that is appropriate for assessing Autism Spectrum Disorders. A thorough assessment should include multiple measures such as interview instruments (e.g., Autism Diagnostic Interview-Revised), direct observations instruments (e.g., Autism Diagnostic Observation Schedule), behavior rating scales (e.g., Direct Observation Assessment Checklist), and standardized adaptive behavior protocols (e.g., Vineland Adaptive Behavior Scales). This checklist is one type of direct observation instrument that may help the assessor determine verification, develop appropriate target s for intervention, and perform follow-up evaluations.

Domains

Ten different domains have been provided that will identify those aspects of the individual and the

environment that are weaknesses or obstacles for the individual and those aspects that are strengths that will serve to assist the individual in overcoming challenges. The checklist allows the assessor to use three different criterion as guides when evaluating an individual for

Verification

eligibility for special education services. DSM refers to the Diagnostic and Statistical Manual-IV of the American Psychiatric Association. The DSM criterion require any six items total, with two items under the Social Competence Domain and one each from the Communication Domain and Atypical Patterns of Behavior Domain (American Psychiatric Association, 1994). NE refers to the Nebraska Department of Education criteria for eligibility for special education services under the label Autism Spectrum Disorder. Nebraska requires that any one item be evidenced under each of four different criterion. Each criteria is

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identified by a corresponding number (i.e., NE-1, NE-2, NE-3, & NE-4). CHAT refers to items that research has suggested may be early diagnostic predictors. There is increasing evidence that ASD can be differentiated from developmental delay in children as young as 12-18 months by observing for these items. There are no specific criterion, although the presence of two or more items would generally be considered to be more predictive (Checklist for Autism in Toddlers; Baron-Cohen, Allen, Gillberg, Br J Psychiatry 1992, 61:839-843)

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Direct Observation Assessment Checklist: Autism Spectrum Disorders


Child Name_____________________________ Date of Assessment _______________ s Interviewer/Observer______________________ Informant_______________________
Domains
Social Competence

Dx
DSM/NE-1

Behaviors marked impairment in nonverbals/gestures Little joint attention/sharing of interests Rarely initiates social interactions Rarely shows appropriate imitation

Observed

Reported

Not Observed/ Don know t

DSM/NE-1 CHAT NE-1

DSM/NE-1 CHAT/NE-1

Shows poor social reciprocity does not enjoy social games (e.g., peek-a-boo) Few appropriate peer relationships Little interest in other children Trouble establishing/maintaining eye contact will not look to an object pointed at

DSM/NE-1 CHAT CHAT/NE-1

CHAT

Communication

DSM/NE-2

DSM /NE-2 CHAT

Echolalia (repetitive/nonfunctional speech) delayed/absent spoken language does not point to indicate interest or desire Little response to language/appears deaf Shows little communicative intent Inability to initiate or sustain conversation no varied make-believe/social imitative play oddities in volume/cadence/pitch Failure to generalize word meanings Pronoun reversal/misuse rarely asks wh questions

NE-2

DSM/NE-2

DSM

NE-2

NE-2

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Domains

Dx

Behaviors

Observed

Reported

Not Observed/ Don know t

Behavior Patterns

DSM/NE-3

NE-3 DSM/51-5

Interest in parts of objects (e.g., wheels) Inappropriate use of objects Rigid adherence to routine/ritual/social rules negative reaction to change/transition preoccupation with topics/details/patterns stereotypic movements unusual interest in sensory stimuli unusual avoidance of sensory stimuli

NE-3

DSM/ NE-3

DSM/NE-3 NE-4 NE-4

Environment
(Circle location below)

demands too high overwhelming stimuli no direct teaching of social interactions need for more positive teaching interactions need help identifying additional reinforcers Inconsistency across people/settings weak collaboration

Home/School/ Clinic

Cognitive / Development

atypical developmental rates or sequence poor abstract thinking/over selectivity delayed intellectual development Difficulty taking another s perspective

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Domains
Physical/ Motor

Dx

Behaviors Gross motor clumsiness Fine motor clumsiness toe walking

Observed

Reported

Not Observed/ Don know t

Play/Leisure

CHAT

CHAT

Poor imaginative/symbolic/pretend play Inappropriate toy play

Academic skills

Poor application of facts Can work independently t Trouble following tasks in sequence

Self-help

Trouble dressing Trouble feeding Trouble toileting Unusual/difficult sleep patterns Dangerous/unsafe behaviors

General/ Vocational

Trouble following directions Trouble working independently Excessive tantrums Physical aggression Trouble following simple rules Self injurious behavior

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Domains

Dx

Behaviors

Observed

Reported

Not Observed/ Don know t

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Principals of Effective Instructional Practice for Individuals with Autism Spectrum Disorders (ASD)
(The following information is adapted from 1997, California Department of Education document, Best Practices for Designing and Delivering Effective Programs for Individuals with Autistic Spectrum Disorders.) An effective instructional program for students with ASD: Is based on current research and effective practices. Determine the most efficient and effective program for the child. Is provided by appropriately trained and competent personnel including parents as appropriate. Make sure staff have specialized training and certification or licensure. Is reflective of the child's areas of strengths and needs that drive the curriculum. Allow the program to integrate techniques or strategies designed to address an array of the child needs. s Includes a variety of methodologies and approaches, which can be integrated. Use strategies that are most cost effective and are compatible with family needs and characteristics. Is based on comprehensive assessment results. Ensure that programming addresses aspects of ASD and have social validity. Is determined by an IFSP or IEP team that is multidisciplinary and includes the parent. Ensure that the program is efficient, consistent, and compatible among providers and settings.

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Is outcome-based. Evaluate the effectiveness of the program. Make sure the services allow for individualization, and can be validated for the specific child.

Is revised, modified or discontinued if any instructional component is not effective in meeting documented needs of the child. Provide ongoing evaluation of programming and intervention outcomes via performancebased assessment and observational data. Have standards for mastery of goals and objectives. Many ASD programs across the country include individual elements of best practice. These programs differ from one another in a variety of ways. Differences

Recommended Characteristics of Services

among programs exist with respect to type and intensity of instruction; program philosophy; instructional techniques; family involvement, and location. All programs should consider selecting instruction (methods, tools, and materials) and adapting the environment (selecting, modifying, varying) to allow the individual child to demonstrate progress with valid measures identified by the curriculum and the IFSP or IEP. Children with ASD, however, require emphasis on strengths while addressing the areas that most interfere with their learning. Programs that are likely to promote growth may encompass the following characteristics. 1. Use applied behavioral analysis to assist a child to learn skills and reduce negative or challenging behaviors. Use behavioral technology (reinforcement, shaping, and prompting) to teach new and expand existing social communication and academic skills. Apply a functional behavioral analysis approach for

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challenging behaviors, looking for the communicative intent of behavior. Plan the intervention to acknowledge the communicative intent. Reinforce positive behaviors in order to eliminate negative behaviors. Use replacement behaviors (substitute or teach a simple acceptable behavior when a student exhibits a challenging behavior). 2. Use an individualized approach to select a developmentally appropriate methodology and level of program. Select from a combination of intervention methodologies such as: discrete trial; environmental modifications; naturalistic teacher moments; and inclusion with typically developing peers.

No single approach is likely to be right for every child. 3. Organize the curriculum around the child current s developmental levels. Analyze the child's level of development in cognitive, adaptive behavior, language, fine and gross motor, socialization and play domains. Plan activities at the child level. s Use intensive language and communication. Use socialization and play when teaching. Use functional and meaningful tasks. Teach basic skills before teaching more complex skills, use task analysis techniques to be sure the precursors for a task have been mastered. 4. Provide a highly structured environment. 36

Limit the amount of distracting visual and auditory stimuli. Use predictable routine with a schedule for each child. Use concrete cues, including meaningful visual stimuli to help the child figure out what is expected as well as to increase independence.

5. Record data and observations to monitor progress and trouble shoot. Observe the child to see what interventions work for the individual child. Provide data on the success of the interventions employed. 6. Assess skills in necessary areas (academic, language/communication, socialization, independent living, fine and gross motor, and recreation and leisure at regular intervals). Use assessment results as a guide for planning what skills to teach next. Monitor the child skills over time. s 7. Generalization and maintenance of skills are built into the program. Conduct instruction across environments using multiple materials, team members, peers and other adults. Provide opportunities for the child to practice skills learned across new environments. 8. Build in teaching interactions with typically developing peers. Create a network for social interaction with peers. 9. Provide parent training and family support. Provide information about intervention options. 1) Collaboration of all team members. Include families, related services providers, and other agencies as appropriate and/or required.

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2) Provide transitional support. Teach the skills needed in the next school situation. Consider what support will be needed.

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Summary of Several Approaches to Intervention Programming


When selecting approaches to use to teach a student with ASD the approaches must match the student specific needs. Planning an s IFSP or IEP requires staff and family to specify the child strengths, s needs, and challenges. Children with ASD display highly individualized learning styles. One child may require a high level of instruction yet the same level would over-stimulate another child. Other factors such as stimulus over-selectivity, the child's motivation for particular stimulation, capacity for sequential learning, and propensity for self-stimulation all must be considered in designing the child's program whether at home or school. Thorough assessment and interfacing of those outcomes contribute to the success or failure of the intervention services. Children with ASD learn in complex ways. Their learning needs and autistic characteristics transform as they develop. To focus on one approach or intervention method, which might temporarily produce a desired result, could ultimately restrict a child's growth. There has been considerable debate over the question of how goals and objectives for young children with ASD should be obtained. Prizant and Wetherby (1993) state, functional approaches (which tend to be behaviorally oriented) and developmental approaches need not be viewed as mutually exclusive. In our experience, however, many educators and clinicians tend to lean heavily towards either developmental approaches or functional/behavioral approaches, to the virtual exclusion of integrating the best practices from both approaches. When activities are functional for students, generally their engagement is enhanced. Educators can find it very challenging to design activities which are simultaneously functional for students with

39

ASD, their peers, and adults around them. When activities are functional for children, they help meet priority needs, goals, or interests of the child. Activities are perceived as functional if they increase skills for independence, normalize interactions, reduce challenging behaviors, expand job opportunities, etc. It is important to recognize that though some skills may not be seen as immediately functional; they may lead to future social or vocational opportunities. For additional information refer to Appendix B. A chart is provided in Appendix C that summarizes several different approaches to intervention programming. The discussion below provides an overview of recommended practices from the literature. The particular combination of approaches selected for an individual child with ASD will be determined by a number of factors related to the child, family, school district and community. No single approach is optimally effective. Developmental concepts can be applied to the intervention program for children with ASD. The emphasis of a developmental model is on

Developmental Concepts

reestablishing the disordered developmental sequence by following the child lead and internal motivation in unstructured interactions, s including play (Greenspan, 1992). Professionals analyze the interaction patterns of the child and family and train the caregivers in strategies for facilitating productive social and emotional interactions, including communication, between the child with ASD and the adults and peers in his/her environments. Both Greenspan (1992) and Bryna Siegel (1991) emphasize that intensive work with the child and family is required. The spontaneous and natural character of the intervention is stressed.

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Behavioral Approaches
The behavior analytic approach holds that, autism is a syndrome of behavioral deficits and excesses that have a

Applied Behavior Analysis (ABA)

neurological basis, but are nonetheless amenable to change in response to specific, carefully programmed constructive interactions with the environment. (Green, 1996) The emphasis on well-sequenced, structured teaching and evaluation methods characteristic of applied behavior analysis makes it uniquely well suited to the goal of effective instruction. A large body of research has shown that children with ASD do not learn naturally from typical environments, but most can learn a great deal given appropriate instruction (Harris & Handleman, 1994; Koegel & Koegel, 1995; Lovaas & Smith, 1989, Schreibman, 1988; Schreibman et al., 1993). Behavior analysis has long been the mainstay of applied research for children with ASD (see Schreibman, Koegel, Charlop, & Egel, 1990, for a comprehensive review). Intervention programming that uses a behavior analytic approach attempts to systematically teach small, observable steps that define a skill. Skills, for which the child demonstrates readiness to learn, are broken into small steps. Each step is taught by presenting an external stimulus or instruction. If the child responds correctly, his or her response is followed by a predetermined positive consequence. If a reinforcement assessment has been conducted, and a potent reinforcer(s) is discovered for a given child, then that reinforcer functions effectively to strengthen the response. Research has shown that intervention/educational programming based on the principles and practices of applied behavior analysis such as modeling, shaping, chaining, and prompting behaviors, and offering physical or written guidance, and schedules are effective. (Koegel and Koegel, 1995)

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These can produce complex and durable improvements in cognitive, social, communication, play, and self-help skills. Applied behavior analysis begins with an instructional orientation. The child with ASD needs to learn competencies that are observable and replicable. Skills selected for teaching should be effective in helping the child to manage his or her environment. The function of the skills selected and taught should be appropriate to the child's age and developmental level. The principal aim of intervention with the child with ASD must be to establish an expanding repertoire of meaningful skills that the child can use in daily interactions. Pivotal Response Training (PRT) was developed to overcome problems of stimulus over-selectivity and motivation

Pivotal Response Training

(Schreibman, Stahmer and Pierce, 1996). Stimulus over-selectivity occurs when the child expanse of attention is too narrow to permit s efficient learning. Motivation is typically limited in children with ASD and prevents generalization of learned responses. In PRT the intervention goes beyond targeting a single behavior; instead it focuses on a set of specific procedures that increase responsively to simultaneous multiple stimulus cues. The logic of teaching pivotal target behaviors is that educators might indirectly affect a large number of individual behaviors. Such an intervention is thought to be more efficient in time and effort required of the child and clinician and also more effective in terms of promoting generalized gains. Discrete trial training is a generic term that involves teaching a person to perform a particular activity by breaking it into simpler components, which can then be rehearsed individually and chained

Discrete Trial Training

42

into a complex sequence. This teaching strategy has been referred to as applied behavior analysis (ABA) or Lovaas training, although these terms have different origins in the behavioral literature and are not actually the same. Discrete trial training can be used within other educational methodologies as a way of teaching the steps needed in completing sequenced tasks and is particularly helpful for children who have motor planning difficulties. While discrete trial training has been documented as effective in teaching linear, chainable sequences, its efficacy has been questioned when teaching behaviors that by their nature need to be interactive rather than reactive and sequenced. Language and social interaction skills are not necessarily linear, chainable skills. The behavior analytic approach has extremely important implications for the understanding of problem behaviors as well as the focus of early intervention programs. In particular, an understanding of the purposes (i.e., communicative functions) of a child's problem behaviors should inform interventionists of specific objectives for early instruction in communication. An instructional strategy that identifies functionally equivalent alternatives to a child problem behaviors is known as Functional s Communication Training (FCT) (Carr et al., 1994). In FCT, targeted skills for instruction, that are selected as equivalent alternatives to problem behavior, should fit within a customary communicative system, be easy to perform, and be effective in producing the desired outcomes (CA Dept, of Ed., 1997).

Functional Communication Training (FCT)

43

Lovaas Training

Effective treatment for severe behavioral disorders is seen to require

early intervention carried out during all or most of the child waking s hours, addressing all significant behaviors in all of the child s environments, by all significant persons, for many years (Lovaas, 1993). This quote describes the basic idea of intensive behavior intervention. A formally conducted intensive program provides 37-40 hours a week of structured learning opportunity. Lovaas asserts that effective treatment requires a comprehensive educational program, i.e., one that addresses all of the child behavioral deviations and individual s learning style (Lovaas, 1996). Intensive 40-hour-a-week programs evolved out of years of research that determined that more really is better, at least for some children with ASD (Lovaas & Smith, 1988). Intensive programs, as recommended by Lovaas, refer to more than the number of hours the child is in treatment each week. Training, curriculum, evaluation, planning and coordination are also intensive. Intensity must be considered on several levels including duration of treatment (e.g., number of hours per day or per week; the number of weeks of intervention per year); the number of environments in which teaching occurs (e.g., school, home, and community); and the educational validity of interventions provided. An intensive program is difficult to achieve, and it demands total commitment on everyone s part. Maintaining quality control over the child's program is an essential part of an intensive program. For example, if a child begins an intensive program that has the quality controls recommended by Dr. Lovaas, he believes it is possible to determine whether that child is appropriate for a 40 hour-a-week program within the first six months of treatment. Most communities lack the resources to deliver the services as

44

intensive as those of Lovaas. There is evidence that less intensive services are also beneficial to children with ASD (Shienkipf and Siege, in press). As more data become available the effect of intensity will become clearer. Quality of teaching expertise, creativity and use of research based techniques may turn out to be as important as intensity.

Biomedical
Children with ASD vary greatly in their degree of medical involvement. They may be healthy, energetic and have a normal sleep pattern or they may be involved with one or more medical problems. The DSM-IV (American Psychiatric Association, 1994) recognizes that neurological abnormalities are reported in a significant percentage of children with ASD: Associated laboratory findings: when Autistic Disorder is associated with a general medical condition, laboratory findings consistent with the general medical condition will be observed. There have been reports of group differences in measures of serotonergic activity, but these are not diagnostic for Autistic Disorder. Imaging studies may be abnormal in some cases, but no specific pattern has been clearly identified. EEG abnormalities are common even in the absence of seizure disorders. Associated physical examination findings and general medical conditions. Various nonspecific neurological characteristics or signs may be noted (e.g., primitive reflexes, delayed development of hand dominance) in Autistic Disorder. The condition is sometimes observed in association with a neurological or other general 45

Biological/Medical Treatments

medical condition (e.g., encephalitis, phenylketonuria, tuberous sclerosis, fragile X syndrome, anoxia during birth, maternal rubella). Seizures may develop (particularly in adolescence) in as many as 25% of cases. Because of these medical problems and others including immune system dysfunction (Tsai & Ghaziuddin, 1992) and neurochemical abnormalities, e.g. raised levels of serum serotonin (Anderson & Hershino, 1987) medical interventions are being sought out as adjunctive treatments for children with ASD. Following a surge in medical research, different medical treatments are being developed each year. A great deal of research is taking place in the genetics of ASD. For a comprehensive review of drug studies and ASD see the article by McDougle, Price & Volkmar, 1994. Repetitive behavior disorders, including abnormally restricted patterns of interest, adherence to rituals, stereotyped motor behavior, object stereotypes, compulsions, and repetitive self-injury have been targeted as possibly responsive to drugs that act by inhibiting the uptake of central serotonin (Lewis, 1996).

Educational
Treatment and Education of Autistic and related Communication handicapped CHildren (TEACCH) TEACCH (Schopler and Mesibov, 1995) uses an eclectic approach

emphasizing structure, manipulation of antecedents, and consistency. TEACCH caters to the child visual processing strengths by organizing s the physical structure of the room. TEACCH seeks to understand the individual and his/her characteristics and take that information and build upon their strengths. The emphasis is on developing appropriate

46

social and communicative behaviors. The guiding principles of the TEACCH program are: To maximize adaptation by teaching new adaptive skills; To develop environmental modifications to accommodate a child's deficit; To maintain parent-teacher collaboration; To provide continuity of structured teaching from preschool to adult years; and To prevent behavior problems from developing. Speech and language pathologists often integrate communication training with the child behavior program to provide a s coordinated opportunity for structured and naturalistic language learning (Parker, 1996). Camarata (1996) defines naturalistic language intervention as, procedures paralleling those employed to teach typically functioning children that produce measurable (and socially valid) change in the morphological, syntactic, semantic, pragmatic, and speech intelligibility aspects of the linguistic system of children with disabilities. Communication is a primary focus of skill development for children with ASD because it is a common area of developmental delay. Communication is crucial for socialization and cognitive development, and it relates to the occurrence of challenging behaviors. In the natural language paradigm, specific targets are taught in a variety of social settings using natural reinforcers

Communication Strategies

Natural Language Paradigm

(interaction with a communication partner or access to desired objects rather than using token or food reinforcers). Natural Language Paradigm (NLP) was designed for use with children with ASD in an

47

educational or clinical setting (Koegel, O Dell, & Koegel, 1987). It is thought to produce more generalized speech for children with ASD. NLP is similar to the mand-model (teaching the child to signal or ask for something) in that teachers systematically prompt verbalizations with mands, model verbalizations if necessary, and reinforce appropriate verbalization during daily routines. NLP procedures differ from other natural language programs by combining several of the positive features of both traditional operant procedures and natural language procedures The Picture Exchange Communication System (PECS) is a communication training program for helping children with ASD acquire functional communication skills. Children using PECS are taught to give a picture of a desired item to a communicative partner in exchange for the item, thus initiating a communicative act for a concrete outcome within a social context (Bondy, 1994). The first goal of PECS is to identify objects that may serve as reinforcers for each child's actions. In subsequent phases, children learn to respond to simple questions, to respond with multi-picture responses and to make requests. Educators and parents can quickly learn how to incorporate picture systems into a visually organized schedule for students, combine picture systems with time-based reward systems, and promote spontaneity in the classroom and the home. Gray Social Stories Unlimited (1994, 1997) is a s strategy to teach social skills through improved

Picture Exchange Communication System

Social Stories

social understanding and the use of visual materials. Individualized for each student and situation, a social story describes a situation in

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terms of relevant social cues and common responses. Guided by a format to gather and write information, professionals and/or parents write a narrative of a targeted social situation. The social story, is created well within the student comprehension ability. This strategy s can be adapted for all ages of students. Another similar strategy, Comic Strip Conversations, creates a visual representation of a conversation to assist students in social situations. (Gray, 1997)

Neurosensory
Sensorimotor Therapies
Sensorimotor information is interpreted by the body (how we

hear, see, feel, smell, taste). The way the body uses the information and the behaviors that can be present if this information is misinterpreted by the body/brain may be problematic from some individuals with ASD. Sensory integration, sensorimotor interaction, and auditory integration training all work from a theoretical basis that the child has atypical responses to sensory input. These approaches work to integrate the senses to provide a more organized sensory system. Sensory approaches include auditory integration training (AIT) (Rimland & Edelson, 1995) and sensory-motor integration training (Ayers, 1979). Berkell, Malgeri, Streit, (1996) present an overview of AIT as a treatment for hyperacusis (hypersensitive hearing) in individuals with ASD, including a review of relevant research, descriptions of the treatment procedure and technology involved, and consideration of current controversies surrounding AIT. The efficacy of AIT remains questionable (Smith, 1996). Use of structured physical activities such as rhythm, body awareness, perceptual motor development, and swimming has been

49

suggested as beneficial activities to engage autistic children (Kraft, 1983). Smith (1996) concluded that Sensory Integration Therapy does not appear to enhance language, control disruptive behavior, or otherwise reduce autistic behaviors. It may offer enjoyable and healthy, physical activity.

Psychotherapy
The psychodynamic approaches view behavioral characteristics as expressions of underlying processes that constitute the real pathology. This approach emphasizes psychological causes and treatment rather than dealing with a physical disease. There is no evidence of a psychogenic cause of ASD (Rimland, 1989). The efficacy of psychoanalytic treatments is also questionable. Smith (1996) discusses the effectiveness of several psychotherapeutic approaches including holding therapy, Gentle Teaching and Options. Smith conclusion is that there is no scientific evaluation of these s therapies with students with ASD.

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Appendix A: Adapting the Environment


Environmental and situational factors can influence the behavior of all children and adolescents. These variables may have an even greater significance for students with ASD. The environmental needs of a child with ASD must be carefully analyzed on an ongoing basis, and included as a component of the child instructional s program. The IFSP or IEP team and in particular the person(s) carrying out the IFSP or IEP should take the following physical environmental considerations into account when implementing the IFSP or IEP: Physical layout of the classroom or instructional area with visually clear areas and boundaries; Selected work areas which are best suited to a particular type of instruction (e.g.: If high frequency sounds from florescent lighting distract the child, reading may need to be taught in an area which has natural light available.); Boundaries needed by the child (e.g. reading is consistently taught on a specific carpet in a specific area of the room); Specific schedules which allow the child to anticipate and predict activities; Individual work systems which tell the child: What work is to be done; How much work is to be done; How the child will know when he/she is finished; and What happens after the work is completed.

Visual organization in instruction to allow the child to use visual learning which is often stronger than auditory learning; and Routines which allow the child to carry out the task in a systematic and consistent manner. .Appendix

B: Functional Activities
51

When planning activities, the following questions may be helpful in negotiating a balance between goals of normalization and those which may serve other important needs for the student with ASD. To identify whether skills are considered to be functional, asking the following questions will lead the team to select the appropriate skills. 1. Will learning the target skill increase the child s independence, adaptability, or vocational success? 2. Are skills taught in such a way that they will be applied and generalized appropriately in various situations throughout the student day? s 3. Are the necessary supports (materials, cues, etc.) available for the child to continue to utilize the new skill? 4. Will learning the skill result in more successful participation in more typical environments? To explore whether the skill is functional from the viewpoint of the student, you may want to ask: 1. Does skill instruction integrate the child unique skills or s interests in various ways? 2. Does the activity reveal and build on skills, interests, or attributes of the child which are/could be valued by others (peers or adults)? 3. Could the skill be serving important personal functions (enjoyment, coping, encouragement, and future open doors), though it does not seem to lead to immediate gains in personal independence.

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Appendix C: Approaches Beliefs:

The approach that works best for the child with autism is the approach that is most specific to a given child needs. These categories are not meant to be all s the reader awareness of the programs available. s
What are the most important program characteristics or components as well as the philosophical beliefs? Manipulation of antecedents or consequences, schedules of reinforcement, stimulus control, behavioral (functional) assessment, functional communication training.

Goals:

What should the child gain?

Strategies:

What are the specific methods used?

What role do family members play?

Parental Role:

Prom

Examples these eme

Behavioral

Normal behavior skill gain; Maximize independence, minimize frustration; Functional skills in developmental domains.

Biomedical

An abnormality in the structure of functioning of the brain underlies the hypothesized Neuropsychological deficit

To develop treatments that are effective in changing outcomes. To develop treatments targeted at the main impairments. Become more independent Gain age appropriate and relevant (functional) skills Behaviors of autism are Addressed through a sensoryintegrative program.

A sampling of strategies: Discrete, distributed, or massed trials; Modeling; Shaping; Chaining; Prompting; Physical guidance; Picture schedules; Reinforcement (immediate/delayed-interspersed/constant); Written, picture, or gestural cues; Punishment. We do not have the research base yet to accept or reject any of these theories as primary. (Sally Rogers, 1997).

Provide coordination of skill training; generalize to home and community

Behaviora Behaviora Options, FCT (Fun Trai Training)

Consult your physician about current medical research findings.

Educational

Can teach skills and accommodate the child s communication, social, and cognitive deficits The body (how we hear, see, feel, smell, taste), interprets sensorimotor information. The way the body uses the information and the behaviors that can be present if this information is misinterpreted by the body/brain. Can teach that social interactions Are rewarding and can form bonding relationships with others. There is no evidence of a psychogenic Cause of autism. The efficacy of psychoanalytic treatments is also questionable.

Neurosensory

Discrete trial training, Structured systematic teaching, Natural language methods, Incidental/Milieu teaching, Structured activities/ schedules, Pivotal Response Training Increased tolerance of sensation, more organized sensorimotor behaviors

Generalize to home & community, Educational team member Facilitate sensory activities

None ava Experime functions Chemical serotonin food aller of abnorm limbic sy TEACCH Commun (Picture C Training language

Sensory I Occupati Neurodev Treatmen PT. Auditory Pivotal R

Psychotherapy

Form sense of own person Gain social relationships Bond with others

Play based therapy Individualized Attention Social interactions

Parents can learn new interaction patterns Fit social interactions into the child s daily routine

Options P Gentle Te Greenspa

This is not an exhaustive list of programs.

These programs may overlap methodologies.

Appendix D: Proposed 92 NAC 51 Language


The following is language proposed by the ASD Ad Hoc Committee to be included in Rule 51. It includes the current rule language as well as proposed changed language. Language to be stricken has a line through it. New language is underlined. 006.04B Autism Spectrum Disorders This may include Autistic Disorder, Rett Disorder, s Childhood Disintegrative Disorder, Asperger Disorder s and Pervasive Developmental Disorder Not Otherwise Specified. 006.04B1a 006.04B1b 006.04B1c 006.04B1d 006.04B1e 006.04B2 A school psychologist or licensed psychologist; The child teacher(s) or a teacher qualified to s teach a child that age; A speech-language pathologist; A school district administrator or a designated representative; and The child parent(s). s In order for a child to be verified as having an autism spectrum disorder, the evaluation shall include the analysis and documentation of the manifestation of severe developmental and educational problems exhibited in varying degrees of atypical behavior in each of the following areas: 006.04B2a Disturbance of developmental rates and sequence. The child developmental profile s reflects varied developmental age levels for skills. The child exhibits delays, arrests, or regressions in physical, social, sensory processing, or learning

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skills. Areas of precocious or advanced skill development may also be present, while other skills may develop at normal or extremely depressed rates. The order of skill acquisition frequently does not follow normal developmental patterns. Atypical development of social competence. The child displays difficulties in social relationships. The child often has difficulty establishing and maintaining reciprocal relationships with others. In young children, characteristics most frequently observed include impaired nonverbal/gestures, little or no eye contact, little or no joint attention, and rarely initiating social interactions or enjoying social games. In older children this may be evidenced through few quality peer relationships and a general lack of awareness of social conventions. 006.04B2b Disturbance of responses to sensory stimuli. The child exhibits unusual or repetitive or meaningful responses to auditory, visual, olfactory, gustatory, tactile, and/or kinesthetic sensory stimuli. The child behavior may vary from high levels of s activity and responsiveness to low levels. The child may exhibit these atypical responses to any or all of the following sensory modalities: sight, hearing, smell, taste, touch, balance, body awareness, and pain. The intensity of the response to these stimuli can range from

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unusually high levels to unusually low levels. 006.04B2c Disturbance of cognitive processes. The child exhibits abnormalities in the thinking process and in generalization. Delayed intellectual functioning may or may not be present. In addition, one or more of the following occurs: 6.04B2c(1) 6.04B2c(2) 6.04B2c(3) Difficulties in abstract thinking, awareness, or judgment; Perseverative thinking; or Impaired ability to process symbolic information. Atypical range of interests and patterns of behavior. The child displays a narrow, encompassing preoccupation with objects, parts of objects, sensations, rituals, or routines. The child may display stereotyped or repetitive body movements and/or motor mannerisms. The focus or intensity of these interests and patterns is abnormal and the child may display marked distress over changes, disruption, or interference with these interests and patterns of behavior. 006.04B2d Disturbance of communication. The child exhibits a qualitative impairment in verbal and/or nonverbal communication. The impairment includes problems that extend beyond speech and language to many aspects of the communicative process. Speech and/or language are either absent, delayed, or disordered. This may include echolalia, mechanical or stilted speech, little response to

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language, pronoun reversals and difficulty expressing emotions. There may be a complete absence of spoken language. Even when verbal language is age-appropriate, oddities may be observed in the communicative process. 006.04B2e Disturbance in relating to people, events and objects. The child displays difficulties in relating to people, events and/or objects. Often the child is unable to establish and maintain reciprocal relationships with people. Their capacity to use objects in an age appropriate or functional manner may be absent, arrested, or delayed. The child responds positively to consistency in environmental events to the point of exhibiting rigidity in routines. The child displays marked distress over changes, insistence on following routines and/or a persistent occupation with or attachment to objects. The child may display a markedly restricted range of interest and/o stereotyped body movements. There may be a lack of interest or an inability to engage in imaginative activities. The areas in 006.04B2a 006.04B2d must adversely affect educational performance.

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Appendix E: Annotated Bibliography

Aarons, M., & Gittens, I. (1992) The handbook of autism: A guide for parents and professionals. New York: Routledge. This book provides practical suggestions and information for parents and practitioners working with children with autism. It explores the history and etiology of autism, issues in diagnosis, and attempts to dispel common myths associated with autism. It discusses instruction, management, and counseling of children with autism. Possible alternative treatments for autism are provided. Anderson, S.R., Taras, M., & Cannon, B.O. (1996). Teaching new skills to young children with autism. In C. Maurice, G. Green, & S.C. Luce, (Eds.), Behavioral intervention for young children with autism: A manual for parents and professionals (pp. 181-194). Austin, TX: PRO-ED, Inc. This chapter recommends educational practices, based largely on applied behavior analysis, for teaching young children in a home-based program. It discusses the structure the learning environment, developing an instructional plan, and instructional methods. It delineates steps for using techniques of shaping, prompts, prompt fading, and chaining. Charlop, M.H. & Haymes, L.K. (1994). Speech and language acquisition and intervention: Behavioral approaches. In J. Matson (Ed.,) Autism in Children and Adults: Etiology, Assessment and Intervention. Pacific Grove, CA: Brooks/Cole. Cohen, D.J., & Volkmar, F.R. (Eds.). (1997). Handbook of autism and

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pervasive developmental disorders (2nd ed.). New York: John Wiley and Sons, Inc. This book is a comprehensive resource on autism and other disorders within the spectrum. Nine sections include chapters by nationally known contributors in the areas of diagnosis and classification, development and behavior, neurobiology, assessment, interventions, public policy perspectives, theoretical perspectives, international perspectives, and personal perspectives. Cohen, S. (1998). Targeting autism: What we know, don know and t can do to help young children with autism and related disorders. Los Angeles: University of California Press. This book provides an overview on autism and then discusses and analyzes currently available treatment approaches, in particular the educational interventions. It blends a description of research findings regarding intervention approaches with personal observations and narratives from parents and adults with autism. Dawson, Geraldine, ed. (1989). Autism: Nature, diagnosis, and treatment. Guilford Press. A textbook. Dawson, G., & Osterling, J. (1997). Early intervention in autism. In M.J. Gurainick (Ed.), The effectiveness of early intervention (pp. 307326). Baltimore: Paul H. Brookes Publishing. This chapter describes eight models for early childhood intervention for children with autism. It evaluates whether programs were effective and whether effectiveness was related to program philosophy and approach or to child characteristics.

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It also identifies common elements of effective programs, presents suggestions for future research, and discusses development of early intervention programs for young children with autism. Dunlap, G., & Fox, L. (1996). Early Intervention and serious problem behaviors: A comprehensive approach. In L.K. Koegel, R.L. Koegel, & G. Dunlap (Eds.), Positive behavioral support: Including people with difficult behavior in the community (pp. 31-50). Baltimore: Paul H. Brookes Publishing Co. This book chapter outlines an ecological approach to early intervention and describes characteristics of a comprehensive program to serve children with severe challenges in communication and behavioral adjustment. Three main components are identified and discussed: (a) development of functional communication skills; (b) provision of inclusive experiences promoting social interactions; and (c) delivery of individualized family support. Frith, U. (1991). Autism and Asperger syndrome. New York: Cambridge University Press. This book discusses Asperger Syndrome, first described by Hans Asperger in the 1940? s as a distinct variant of autism. Diagnostic criteria, clinical case studies and personal accounts from clinical practice are placed in a new theoretical framework. Frith provides the first English translation of Asperger paper s and describes how his insights reflect a modern awareness of the broad continuum of autistic disorders. Practical suggestions on the education and management of children with autism are provided.

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Frost, C., & Bondy, A. (1994). PECS: The picture exchange system training manual. Cherry Hill, NJ: pyramid Educational Consultants, Inc. (Available from Pyramid Educational Consultants, Inc., 5 Westbury Drive, Cherry Hill, NJ 06008, (888) 732-7462) This manual provides the information necessary to implement the Picture Exchange Communication System (PECS). This is an augmentative training package designed to allow children with autism and other communication deficits to initiate communication. The manual includes suggestions on assessing reinforcers, prompting, fading and other Gerdtz, J., & Bregman, J. (1990). Autism: A practical guide for those who help others. New York: Continuum Publishing Company, This is a guidebook for those who work with children, adolescents, adults with autism, and their families. It is designed to help practitioners adapt theories of autism to the practical and unique needs of individuals and families living with autism. Gillberg, C., & Coleman, M. (1992). The biology of the autistic syndromes (2nd ed,). London: Mac Keith Press. This updated edition reviews the literature in areas of epidemiology, genetics, biochemistry, immunology, brain imagery, neuropsychology, and other biologically based research in autism. It suggests and outlines components of a full medical examination. It discusses known pharmacological and medical therapies (including those still under investigation), and discusses current theories on the origins of autism.

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Gray, C. (1994). Comic strip conversations: Colorful illustrated interactions with students with autism and related disorders. Arlington, Texas: Future Education. This booklet describes an instructional strategy that uses line drawing illustrations to support the development of successful conversations and interactions -- both understanding the language of others (what is said and what is meant) and responding appropriately. Gray, C. (1994). The original social story book. Arlington, Texas: Future Education. This book, formerly titled The Social Story Book, contains updated, specific instructions for writing and implementing social stories. Gray, C. (1997). Social stories and comic strip conversations: Unique methods to improve social understanding. Arlington, Texas: Future Education. This booklet is a collection of articles and social story materials. The materials describe the social story approach, including general guidelines for writing and implementing this instructional method to help students use appropriate social interaction skills. Gray, C. & Jonker, S. (1997). New social stories. Arlington, Texas: Future Education. This book originally titled The Social Story Book 1994, contains examples of social stories on 99 topics. The last chapter provides suggestions for getting started on the process of writing a social story.

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Greenspan, S. I., Kalmanson. B., Shanhmoon-Shanok, R., Wieder, S., Williamson, G.G., & Anzalone, M. (1997). Assessing and treating infants and young children with severe difficulties in relating and communicating. Washington, DC: Zero to Three. This book provides information on evaluating and treating young children diagnosed with multisystem developmental disorder (MSDD), pervasive developmental disorders (PDD), and autistic disorder. Individualization and integration of evaluation and treatment is emphasized. Strategies are provided for working with families, promoting child engagement, and designing a therapeutic village in which children can be raised. Groden, G., & Baron, M. G. (Eds.). (1991). Autism: Strategies for change. A comprehensive approach to the education and treatment of children with autism and related disorders (2nd ed.). New York: Gardner Press. This volume represents the philosophy of a comprehensive approach to services for children with autism and related disorders. Covers behavior assessment; parent and family involvement; medical, perinatal, and neonatal concerns; intellectual functioning; and behavioral programming. A systems research is discussed in assessment and Harrington, K. (1998). For parents and professionals: Autism. East Moline, IL: LinguaSystems, Inc. [Available from LinguaSystems, Inc., 3100 4th Avenue, East Moline, IL 61244-9700, (800) 776-4332] This book provides information about autism and intervention activities that are adapted across three developmental levels in the areas of attending, language, self help, pragmatics, and cognition. Family stories and experiences are interwoven

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throughout. The author is the parent of a young adult with autism and also is a speech-language pathologist. Harris, S., & Handleman, J. (Eds.). (1994). Preschool education programs for children with autism. Austin, TX: PRO-ED. This book presents information on 10 different preschool education programs for children with autism. The contributors describe their programs in the following areas: program structure and context, diagnosis and assessment of the children, teaching staff and administrative structure, curriculum, integration of children with autism with normally developing peers, behavior management procedures, family involvement, and outcome data. Hodgdon L. A. (1995) Visual strategies for improving communication. Troy, MI: Quirk Roberts Publishing. This is a how to manual, based on a body of research suggesting that individuals with autism spectrum disorders are more successful functioning in their environments when supported with visually-mediated communication techniques, including objects, pictures, line drawings, and/or print. The collection of tools broadens the focus of communication to include use of visual strategies to improve the individual s receptive language ability. There are a number of examples and descriptions of the construction and use of visual communication tools, intended for use at home, school, childcare settings, and work. Holmes, D.L. (1997). Autism through the lifespan: The Eden Model. Bethesda, MD: Woodbine House, Inc.

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This book describes the Eden Family Services program in Princeton, New Jersey, and describes the philosophy of, commitment to, and concept of providing comprehensive services to children and individuals throughout their life. Chapters include information on autism, behavior modification, placement, treatment, staffing issues, accountability, community integration, parental roles, and their policy of not excluding anyone. Examples and case histories are provided. Johnson, C., & Crowder, J. (1994). Autism: From tragedy to triumph. Boston: Brander Publishing Co. This book discusses aspects of the discrete trial method of treatment and includes a foreword by Dr. Ivar Lovaas. The book is organized in two main sections: diagnosis and treatment. Jordan, R. & Powell, S. Understanding and Teaching Children with Autism. (Wiley). This book includes information on modeling. Koegel, R., & Koegel, l. (1995). Teaching children with autism: Strategies for initiating positive interactions and improving learning opportunities. Baltimore: Paul H. Brookes. This book is designed to provide a conceptual and practical guide for teaching children with autism. It presents strategies that are based on positive interactions and aimed at maximizing developmental potential and providing a foundation for learning. Lovaas, I.O. (1981). Teaching developmentally disabled children: The ME book. Baltimore: University Park Press.

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This book provides step-by-step instructions for a home-based, discrete trial behavior modification program for children with autism. Chapters address basic self-help skills, getting ready to learn, and detail a range of language-based trial activities. Luce, C., Green, G., & Luce, S.C. (Eds). (1996). Behavioral intervention for young children with autism: A manual for parents and professionals. Austin, TX: Pro-Ed, Inc. This book provides an overview and rationale for behavioral intervention for young children with autism. Chapters include information on choosing effective treatments, evaluating treatment claims, a review of the research, selecting teaching programs and curricula, individualization, assessment, staffing and personnel qualifications, the University of California at Los Angeles model, working with families, organizing community support, inclusion, and incorporating specialized therapies. Marcus, L.M., Lansing, M., & Schopler, E. (1993). Assessment of the autistic and pervasive developmentally disordered child. In D. Willis & J. Culberton (Eds.), Testing young children (pp. 319-344). Austin, TX: PRO-ED. This chapter reviews assessment strategies and techniques used within the Division of Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) for young children with autism. It reviews methods of structuring the test situation and useful tests. A case study is presented to illustrate how to use assessment data to develop a teaching program. Mauk, J.E., Reber, M., & Batshaw, M.L. (1997). Autism and other pervasive developmental disorders. In M.L. Batshaw (Ed.), Children

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with disabilities. (4th ed.) (pp. 425-448). Baltimore: Paul H. Brookes. This chapter provides a historical perspective, defines pervasive developmental disorders, presents information on prevalence and distinguishing characteristics, and describes recommendations and resources for evaluation and treatment. Information on pharmacological management and unproven therapies is included, as well as two case examples. McClannahan, L.E., & Krantz, P.J. (1999). Activity schedules for children with autism: Teaching independent behavior. Bethesda, MD: Woodbine House. This book incorporates information learned about activity scheduling at the Princeton Child Development Institute over the last 10 years. Activity scheduling teaches children to use pictures or symbols, symbols and words, and can reduce the need for adult prompting and supervision as well as increase child Mesibov, G.B. (1994). A comprehensive program for serving people with autism and their families: The TEACCH model. In J.L. Matson (Ed.), Autism in children and adults: Etiology, assessment and intervention (pp. 85-97). Belmont, CA: Brooks and Cole. This chapter details the history, structure, and services of the Division of Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH), the North Carolina state-mandated agency established in the early 1970 s. It reviews various program components including diagnosis, assessment, treatment, consultation, research, and training. Quill, K. (1995). Teaching children with autism: Strategies to enhance communication and socialization. Albany, NY: Delmar.

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This book describes teaching strategies and instructional adaptations that promote communication and socialization in children with autism. It offers specific strategies that capitalize on individual strengths and learning styles to support children s exploration and interactions with people. Teaching principles and practices are based on applied research conducted during the previous decade. Schopler, E., Mesibov, G.B., & Kunce, L.J. (Eds.). (1998). Asperger Syndrome or high-functioning autism. New York: Plenum Press. Chapters in this book include the history of the syndrome, diagnostic subtyping issues, differential diagnosis, reviews of the literature comparing Asperger syndrome with highfunctioning autism, nonverbal learning disabilities, and links to the schizoid personality in childhood. Contributors provide information on topics such as nueropsychological issues, treatment issues, and related conditions. Autobiographical essays are included. Schopler, E., & Mesibov, G. (Eds.). (1994). Behavioral issues in autism. New York: Plenum Press. A comprehensive approach to behavioral characteristics of autism is presented. Contributors discuss assessment, treatment, special topics, and a variety of behavioral issues in autism.

Schopler, E., & Mesibov, G. (Eds.). (1988). Diagnosis and assessment in autism. New York: Plenum Press. This book is designed to advance understanding of issues in diagnosis and assessment. It presents information on diagnostic

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and assessment instruments along with analyses of their contributions to the field. Schopler, E., & Mesibov, G. (Eds.) (1995). Learning and cognition in autism. New York: Plenum Press. This book presents an introduction to cognitive approaches to understanding and working with people with autism. It discusses general issues, thinking and learning processes, social cognition, education, and treatment. Schopler, E., Van-Bourgondien, M.E., & Bristol, M. (Eds.). (1993). Preschool issues in autism. New York: Plenum Press. This volume addresses aspects of autism in young children seen from the perspective of normal child and family development. It includes issues of diagnosis, assessment, and treatment (global and specific) from theoretical, programmatic, practical, and legal viewing. Schreibman, L. (1988). Autism. Newbury Park, CA: Sage. Chapter topics in this book include behavioral characteristics, diagnosis and evaluation, and etiology (social, cognitive, and biological). It discusses behavioral excesses and deficits and specific and general behavioral treatment methods. Shriver, M.C., Allen, K.D., Mathews, J.R. (Eds). (1999). Mini-series: Assessment and treatment of children with autismin the schools. School Psychology Review, 28 (4). This mini-series of five articles provides empirically-based information to school psychologists about the assessment and treatment of children with autism. Topics were chosen to present state-of-the-art information about assessment and

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treatment that would be directly applicable to the day-to-day practice of school psychologists. Five different articles cov er 1) assessment of autism in the schools, 2) a review of the most visible treatment programs and the research regarding these programs, 3) current behavior analysis research on effective teaching of children with autism, 4) a review of the current research on designing an effective curriculum for a child with autism, and 5) a discussion of how best to consult with teachers to effectively implement interventions in the classroom. Siegel, B. (1996). The world of the autistic child: Understanding and treating autistic spectrum disorder. New York: Oxford University Press. The first section of this book provides an overview of autism, including family issues, diagnosis, social development, and communication. The second section discusses treatment approaches, finding resources, early intervention, and use of psychoactive medications. Sigmon, M., & Capps, L. (1997). Children with autism: A developmental perspective. Cambridge: Harvard University Press. This book describes differences in development between children and individuals with autism and those who are normally developing from infancy through adulthood. The authors propose that deficits in social understanding begin in early infancy and they discuss how those deficits affect development throughout the life span. Volkmar, F.R., Klin, A., & Cohen, D.J. (1997). Diagnosis and classification of autism and related conditions: Consent and issues. In D. Sohen & F. Volkmar (Eds.), Handbook of Autism and Pervasive

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Developmental Disorders (2nd ed) (pp. 5-40). New York: John Wiley & Sons. This chapter summarizes diagnostic concepts and the empirical basis for the current definitions of pervasive developmental disorders. Information includes issues in classification, autism as a diagnostic concept, approaches to categorical definitions, and a historical diagnostic evolution and critique of autism and related conditions under the spectrum of PDD as defined by the DSM-III, DSM III-R, the DSM IV field trials, and the ICD-10. Watson, L., Lord, C., Schaffer, B., & Schopler, E. (1989). Teaching spontaneous communication to autistic and communication handicapped children. New York: Irvington Publishers, Inc. This book presents a communication curriculum designed to provide methods for assessing and teaching communication skills to students with autism and related disorders. These materials have been tested extensively under the direction of the Division of Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH).

Tests for Autism

Test:

Autism Screening Instrument for Educational Planning: Authors: David A. Krug, Joel R. Arick, & Patricia J. Almond, 1978 Pro-ed 8700 Shoal Creek Boulevard Austin, TX 78757

Second Edition

Available from:

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The manual states that this measure is designed to help professionals identify individuals with autism and to provide information needed to develop appropriate educational plans. It is comprised of five (5) separately standardized sub-tests which can be used for verification, educational program planning, and analysis of progress. The Autism Behavior Checklist is a sub-test intended to be used with all individuals thought to be autistic, regardless of chronological age or functioning level. The Sample of Vocal Behavior, Interaction Assessment, Educational Assessment, and Prognosis of Learning sub-tests are intended for individuals functioning at language and social ages between 3 and 49 months. Test: The Childhood Autism Rating Scale Eric Schopler, Robert J. Reichler, and Barbara Rochen Western Psychological Services 12031 Wilshire Boulevard Los Angeles, CA 90025-1251 The manual describes the Childhood Autism Rating Scale as a 15-item behavioral rating scale developed to identify children with autism, and to distinguish them from developmentally handicapped children without the autism syndrome. It further distinguishes children with autism in the mild to moderate range from childen with autism in the moderate to severe range. Test: Gilliam Autism Rating Scale James E. Gilliam, 1995 Pro-ed 8700 Shoal Creek Boulevard

Author:

Available from:

Author:

Available from:

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Austin, TX 78757 The manual states that the instrument is designed for the assessment of individuals aged 3 through 22 who have severe behavioral problems. Its purpose is to help professionals diagnose autism." Items are based on the definition adopted in 1994 by the Autism Society of America and on criteria for autistic disorder published in the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition.

Test: Psychoeducational Profile Author: Eric Schopler and Robert J. Reichler Available from: Child Development Products Division TEACCH Department of Psychiatry School of Medicine, Health Affairs University of North Carolina Chapel Hill, NC 27514 This instrument provides a developmental approach to the evaluation of imitation, perception, motor, eye-hand coordination, cognitive performance, and verbal skills most appropriate for children functioning at preschool age level, from 1 to 12 years chronological age.

Tests of Communication
Test: Clinical Evaluation of Language Fundamentals: Third Edition Authors: Eleanor Semel, Elisabeth Wiig, and Wayne Secord, 1995 Available from: The Psychological Corporation Harcourt Brace Jovanovich, Inc. San Antonio, TX This test measures understanding and use of language -diagnosis of language disorders -- of children from 6 to 21 years of age, using full-color stimulus materials. The CELF-3 norms

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were standardized on more than 2,400 children and adults.

Test: Communication and Symbolic Behavior Scales Authors: Amy Wetherby and Barry Prizant, 1993 Available from: Riverside Chicago, IL The measure assesses three categories of communicative functions: social interaction skills -- use of eye contact, gestures, and affective signals, behavior regulation or requesting skills -use of gestures and eye contact to direct attention and elicit aid in obtaining an object or event, and joint attention skills. Test: Preschool Language Scale: Third Edition Authors: Irla Zimmerman, Violette Steiner, and Roberta Pond, 1992 Available from: The Psychological Corporation Harcourt Brace Jovanovich, Inc. San Antonio, TX

This instrument assesses the receptive and expressive language skills in infants and young children -- ages birth through 6 years of age.

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Appendix F: References
92 NAC 51, Title 92, Nebraska Administrative Code, Chapter 51. Nebraska Department of Education Rule 51, regulations and standards for special education programs. Effective Date, October 3, 1999 (Revised). American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anderson, S.R., Hiroshino, Y. (1987). Neurochemical studies of autism. In D. J. Coheb & A. Donnellan (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.166-191) New disorders (pp.166-191) New York: Wiley. Ayers, A. J. (1979). Sensory integration and the child. Los Angeles: Western Psychological Services. Bayley (1969). Bayley Scales of Infant Development. The Psychological Corporation. Harcourt Brace Jovanovich, Inc. Berkell, D.E., Malgeri, S.E., Streit, M.K. (1996). Auditory integration training for individuals with autism. Education & Training in Mental Retardation & Developmental Disabilities, Vol 31(1) 66-70. Bondy, A.S. & Frost, L. A. (1994). The picture exchange communication system. Focus On Autistic Behavior, Vol. 9 (3) 1-19. Bristol, M. and Cohen, D., et. al. (1996). State of the science in autism: Report to the National Institutes of Health. Journal of Autism and Developmental Disorders, Vol, 26, No. 2. California Department of Education (1998). Best practices for designing and delivering effective programs for individuals with autistic spectrum disorders. California Department of Education, Sacramento, CA. Camarata, S.M. (1996), On the importance of integrating naturalistic language, social intervention, and speech-intelligibility training. In Koegel, L.K, Koegel, R.L. & Dunlap, G. Positive Behavioral Support. Baltimore: Paul H. Brookes Publishing Co.

Carr, Edward G., L. Levin, G. McConnachie, J.I. Carlson, D.C. Kemp,

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and C.E. Smith (1994). Communication-based intervention for problem behavior. Baltimore, Brookes Publishing. Dawsen, G. & Galpert, L. (1986). A developmental model for facilitating the social behavior of autistic children. In E. Schopler & G.B. Mesibov (Eds.), Social behavior in autism (pp. 237-261). New York: Plenum Press. Gerlach, E. (1993). Autism Treatment Guide. Eugene, OR: Four Leaf Press. Goossens C., Crain, S., & Elder, P. (1992). Engineering the preschool , classroom environment for interactive symbolic communication. Wauconda, IL: Don Johnston Inc. Gray, C. (1994). New social stories (formerly, The social storybook). Texas: Future Education. Gray, C. & Jonker, S. (1997). New social stories. Arlington, Texas: Future Education. Green, G. (1996). Early behavioral intervention for autism: What does research tell us. In Maurice, Green & Luce (Eds.) Behavioral Interventions for Young Children with Autism, (pp. 29-44) Austin, TX: Pro-ed. Greenspan, S. I. (1992). Infancy and early childhood: The practice of clinical assessment and intervention with emotional and developmental challenges. Madison, CT: International University Press. Hayes, S.C., Nelson, R.O., & Jarrett, R.B. (1987). The treatment utility of assessment: A functional approach to evaluating assessment quality. American Psychologist, November, 963-974. Janzen, Janice, E., 1996. Understanding the nature of autism: A practical guide. The Psychological Corporation: San Antonio, Texas. Koegel, R.L. & Koegel, L.K. (1995). Teaching children with autism: Strategies for initiating positive interactions and improving learning opportunities. Baltimore: Paul Brooks. Krug, Arick, & Almond (1979). Autism Screening Instrument for Educational Planning. Portland State University, Portland, Or. Krug, Arick, & Almond (1993). Autism screening instrument for educational planning (2nd edition, examiner manual. Austin, Texas: s

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Pro-Ed. Lewis, M.H. (1996). Brief report: Psychopharmacology of autism spectrum disorders. Journal of Autism and Developmental Disorders, 26, 231-235. Lord, C., Rutter, M., Goode, S., Heemsvergen, J., Jordan, H., Mawhood, L., & Schopler, E. (1989). Autism diagnostic observation schedule: A standardized observation of communicative and social behavior. Journal of Autism and Developmental Disorders, 19, 185-212. Lovaas, O.I. (1993). The development of a treatment-research project for developmentally disabled and autistic children. Journal of Applied Behavior Analysis, 26, 617-630. Marcus, L.M. & Stone, W.L. (1993). Assessment of the young autistic child. In E. Schopler & M.E. Van Bourgondien (eds), Current issues in autism. (pp 149-173). New York: Plenum Press. Maurice, C., Green, G., & Luce, S. (1996). Behavioral Intervention For Young with Autism: A Manual for Parents and Professionals. Austin, TX: Pro Ed. McDougle, C., L.H. Price, & F. Volkmar (1994). Recent advances in the pharmacotherapy of autism and related conditions. The Communicator, Vol. 7, No.1. Parker, R. (1996). Incorporating speech-language therapy into an applied behavior analysis program. In Maurice, Green & Luce (Eds.) Behavioral Interventions for Young Children with Autism, (pp.297-306) Austin, TX: Pro-ed. Peck, C.A. & Schuler, A.L. (1987). Assessment of social/communicative behavior for students with autism and severe handicaps: The importance of asking the right question. In T. Layton (Eds.), Language and Treatment of Autistic and Developmentally Disordered Children. Springfield, IL: Charles Thomas. Powers, M. D. (1992). Early intervention for children with autism. In D. E. Berkell (Ed), Autism: Identification, education and treatment. Hillsdale, NJ: Erlbaum. Prizant, B.M. & Wetherby, A. (1993). Communication in preschool autistic children. In E. Schopler, M. van Bourgandien & M.

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