The Child As A Whole

The Child as a Whole: Why Behavioral and Biomedical Interventions are both Critical to Growth and Recovery Doreen Granpeesheh, Ph.D. B.C.B.A-D

Center for Autism and Related Disorders, Inc

Today’s Presentations What is Autism: A whole body condition The Synergistic Effects of ABA and Biomedical Interventions working together  Sudden and dramatic changes in behavior when medical interventions are put in place • Case Studies

What is ABA (Applied Behavior Analysis)  What is good ABA? • How can you gain access to it?

What is Autism?  Pervasive Developmental Disorders  Impairments in two or more areas of development

• Autism    

Impaired Social Interaction, Impaired Communication Restricted, Repetitive Behaviors 6 or more symptoms

• Asperger’s Disorder  Impaired Social Interaction  No Language delay  No Cognitive delay

• PDDNOS  Delays in all three areas (Social, Communication and Stereotypy)  Fewer than 6 symptoms

What is Autism? Communication:  My child is delayed in language  My child has no eye contact

Social Behavior:  My child doesn’t interact with anyone  My child doesn’t play with others

Stereotypy:  My child does repetitive behaviors (lining up objects, opening closing door, turning on and off the lights)  My child is inflexible and needs routines

Anything else? Challenging Behaviors? Sensory Sensitivities? Medical Illnesses?

AUTISM Minimize Exposure Genetic Predisposition To Toxins

Metals Pesticides Antibiotics

Treat the Underlying Medical Disorders

Physical Conditions Oxidative Stress Decreased Methylation Immune Dysfunction GI Inflammation

Teach New Learning Patterns

Brain Disorders Hypoperfusion Hypo and Hyper sensitivity to stimuli Different Learning Patterns

Reduce/Eliminate Symptoms

Behavioral Symptoms Delayed Language Delayed Social Skills Stereotypy

Minimize Exposure to Toxins Make sure your physician only uses antibiotics when necessary Avoid pesticides (go organic) Spread out vaccinations to reduce stress on immune system Check for metal toxicity to determine need for chelation (toxic metal assay, porphyrins)

Treat Underlying Medical Illness Immune Markers  Check for cell mediated immune activation (neopterin/biopterin)  Check for Strep Titers • ASO: Antistreptolysin O • anti-DNase B: Anti-Deoxyribonuclease B

 Immunoglobulin Subsets (Antibodies that respond to bacteria, viruses, fungus, etc)  Vaccine Titers

Discuss Possible Treatments with your physician: IVIG, Spironolactone

Treat Underlying Medical Illness Oxidative Stress Markers (reduced glutathione: found in every cell…helps neutralize free radicals)  To identify need for Anti Oxidants

Decreased Methylation/transulfation (fasting plasma cysteine or methionine)  To identify possible benefit of methyl B12

Treat Underlying Medical Illness Evaluate and Treat GI Disorders  Nutrition  Diet  Medication (anti-inflammatory, steroids, anti-fungals)

Reduce Hypoperfusion  HBOT?

Teach New Learning Patterns Evaluate need for modified sensory input  Visual  Auditory  Tactual

ABA: Applied Behavior Analysis  “30 years of research demonstrated the efficacy of Applied Behavioral methods in reducing inappropriate behavior and in increasing communication, learning and appropriate social behavior” Surgeon General, 1999

ABA and Biomed working together

Medical Treatment

ABA

Eliminate Triggers Stabilize condition Achieve Health

Increase Skills Decrease Challenging Behaviors Generalize to Daily Living

Because a healthy child sleeps better, feels better and can learn better!

Why would a behaviorist care about biomedical interventions? 1990: Andrew was diagnosed with Celiac… we placed him on a diet and he recovered within a year! 1992: I began to notice a pattern of children with extremely high use of antibiotics! This must be leading to some abnormal flora! 1993: Emily had fungus on her nails… treated with antifungals, her behavior changed drastically!

Preliminary Outcome Study:1996

79 children 63 boys

16 girls

Average age at intake: 39.1 months Average IQ at intake: 76.8 (borderline) Length of time in treatment: 3 years

Preliminary Outcome Study:1996

High Intensity

Low Intensity

More than 25 hours/week

Less than 25 hours/week

44 children

35 children

Matched on age, IQ, language, adaptive behavior

Results: Outcome 1996 Mean Client IQ Pre- and Post-Treatment

IQ Standard Score

100 High Intensity

95 90 85 80 75 70

Low Intensity 1 Pre-Treatment

2 Post Treatment

Mean Adaptive Functioning Pre- and Post-Treatment Vineland Standard Score

100 95 High Intensity

90 85 80 75 70

Low Intensity

65 60

1

Pre-Treatment

2

Post Treatment

Normal Cognitive Functioning WPPSI: Pre- & Post-ABA Early Intervention

Pre-Test

130 120

Post-Test

110 100 90

Intelligence Quotient

80 70 60 50 40 30 20 10 0 20

22

27

29

29

30

30

31

Average Therapy Hours Per Week

31

31

32

34

38

Why didn’t we publish this? 1996 Outcome Study Confounding Variable:

• A higher percentage of children in the high intensity group were receiving biomedical interventions! • Was the improvement in IQ and adaptive skills due to ABA or due to the medical interventions or a combination???

THE KEY IS TO IDENTIFY WHAT IS CAUSING AUTISM IN YOUR CHILD! TREAT THE UNDERLYING CAUSE… AND THEN USE ABA TO TEACH YOUR CHILD ALL THE SKILLS HE DIDN’T LEARN WHEN HE WAS MOST AFFECTED! ALL CHILDREN NEED AND BENEFIT FROM ABA!

1987: Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children Experimental Group: N=19 47% 40 hours/wk Recovered! 3 yrs 10 hours/wk 10 hours/wk UCLA/NPI 3 2% yrs Recovered 3 yrs

Control Group 1: N=20

Control Group 2: N=20

Children with Autism DO Recover! There is NO magic pill It is hard work and can take a long time Let’s look at some case studies of children who improved significantly with a combination of medical and behavioral treatment

Mathew R Diagnosis: Autism Intake:  Age: 3.5  Deficits: no eye contact, speech consisted of 5 one word requests, tantrums by throwing self on floor and screaming, no interest in peers, not toilet trained, visual and ritual ssb occurred 90% of time

Treatment:    

1 year 7 months with CARD Average intensity of 40 hours/week GFCF and probiotics Anti-Fungal medications (Diflucan, Nistatin)

Current:  Age: 5.1  In typical preschool with aide only for social interactions  Maintains conversation, asking for information, mand, tact and answer why/because questions, plays with peers up to 5 minutes interactively, very advanced in academic skills, few visual ssb, no tantrums anymore.

Mathew: challenging Behaviors GFCF Diflucan + Nystatin + Probiotics

350 300

Frequency

250 200 150 100 50 0 Feb

Mar

April

May

June

July

Aug

Months

Sept

Oct

Nov

Tantrums

Non-Compliance

Screaming

Visual SSB

Verbal SSB

Ritual SSB

Dec

Jan

Feb

Mathew

D.R. Diagnosis: Autism Intake:  Age: 2.11  Deficits: receptive vocabulary of 10 words, 3 expressive words used for needs (juice, open, ball), no eye contact, severe tantrums, crying, aggression and elopement, ssb included gazing, mouthing objects and toe walking.

Treatment:  1 year 10 months with CARD to date  Average intensity of 30 hours/week  Specific Carbohydrate Diet

Current:  Age: 4.9  In typical preschool with aide  175 mastered receptive labels, mands and tacts with all items using full sentences, maintains eye contact up to 8 seconds, responds to name by making eye contact and saying “yes” or ‘what”, answers 23 social identification questions, interacts with adults average of 10 minutes/peers 2 minutes. Ssb reduced but still exist, aggression and noncompliance have extinguished.

D.R.: New Skills per month

New Skills per Month

250

ABA + IgG Allergy Elimination Diet + Feingold Diet + Rotation diet

ABA + Specific Carbohydrate Diet

200 150 100 50 0 Nov-03

Dec-03

Jan-04

Feb-04

Months

Mar-04

Apr-04

May-04

Jun-04

DR

D.R.: Cumulative Skills

Cumulative Skills per Month

1400 1200

ABA + IgG Allergy Elimination Diet + Feingold Diet + Rotation diet

ABA + Specific Carbohydrate Diet

1000 800 600 400 200 0 Nov-03

Dec-03

Jan-04

Feb-04

Months

Mar-04

Apr-04

May-04

Jun-04

DR

Frequency of Stereotypy per Month

D.R.: Stereotypy per month

800 700 600

ABA + IgG Allergy Elimination Diet + Feingold Diet + Rotation diet

ABA + Specific Carbohydrate Diet

500 400 300 200 100 0 Nov

Dec

Jan

Feb

Mar

April

May

June

M onths

DR Visual SSB

Verbal SSB

Oral Motor SSB

Tactile SSB

Frequency of Aggression per Month

D.R.: Aggression per month

100 90 80 70

ABA + IgG Allergy Elimination Diet + Feingold Diet + Rotation diet

ABA + Specific Carbohydrate Diet

60 50 40 30 20 10 0 Nov

Dec

Jan

Feb

Mar

Months

April

May

June

DR

Emma Diagnosis: Asperger’s Syndrome Intake:  Age: 3.4  Deficits: poor eye contact, extensive vocabulary but did not use language with peers, self-isolated at school, severe tantrums, non compliance and aggression with family, visual self-stimulatory behaviors, severe ritualistic behavior, no Theory of Mind

Treatment:    

10 months with CARD Average intensity of 10 hours/week Lexapro Pro DHA and CorOmega

Exit:  Age: 4.2  In typical kindergarten with no aide  Initiated conversations with peers, many friends, no tantrums or aggression, very advanced in academic skills and very popular in school

Emma: Challenging Behaviors per month ABA

ABA + Lexapro

ABA + ProDHA + Coromega

Frequency per Session

7 6 5 4 3 2 1 0 April

May

June

July

Aug

Sept

Oct

Nov

Dec

Months

Tantrums

Non-Compliance

Ritual SSB

Emma

Emma: New Skills per month

ABA + Lexapro

ABA

ABA + ProDHA + Coromega

New Skills per Month

120 100 80 60 40 20 0 Mar 04

April 04

May 04 June 04

July 04

Months

Aug 04

Sept 04

Oct 04

Nov 04

Dec 04

Emma

A. D. Diagnosis: Autism Intake:  Age: 2.11  Deficits: had 3-4 word utterances but no spontaneous language, selfisolated around peers, no safety awareness, toe walking, licking hands, had difficulty inhibiting responses and would often touch people’s hair or clothing.

Treatment:    

3 year with CARD Average intensity of 25 hours/week Anti-fungals Chelation

Exit:  Age: 5.11  In typical kindergarten without aide  Initiates, joins, transitions conversations with peers, has many friends, good understanding of others perspectives, no challenging or selfstimulatory behaviors present. Normal range on all exit testing (IQ, language, TOM, EF)

A.D.: Challenging Behaviors per month ABA + Antifungal + Chelation

ABA

12 10 8 6 4 2

Fidgeting Grabbing

June

May

AD

M onth

Elopement Running

April

March

Feb

Jan

Dec

Nov

Oct

Sept

Aug

July

June

0 May

Frequency per Hour

14

Leaning Screaming

A.D.: New Skills per month ABA + Antifungal + Chelation

ABA

200

150

100

50

M onth

June

May

April

March

Feb

Jan

Dec

Nov

Oct

Sept

Aug

July

0 June

New Skills per Month

250

AD

111-TEM - 2 year old male - Completed 80 dives in 14 weeks - Mother reported tremendous gains in

language and socialization; significant changes were also noted by examiner during post-testing. - Supervisor reported that participant acquired many skills since starting the study.

ADOS Lower scores are better ADOS 14

12

Total Score

10

8

Pretest Post-test Autism Spectrum Cutoff

6

Autism Cutoff

4 Significant improvement on score Commication and Socialization score on the ADOS; both in autism spectrum range

2

0 ADOS Com

ADOS Soc ADOS Area

ADOS Tot

ABC Lower is better Aberrant Behavior Checklist 120

100

80 Lethargic/Withdrawal Significant decrease in total score near end of study

60

Stereotypic Beh Hyperactivity Inappropriate Speech Total Score

40

20

Week

et io

n

4 Co m

pl

k1

3 W ee

k1

2 W ee

k1

1 W ee

k1

0 W ee

k9

k1 W ee

W ee

k8 W ee

k7 W ee

k6 W ee

k5 W ee

k4 W ee

k3 W ee

k2 W ee

2

k1 W ee

BL

1

0 BL

Score by Area

Irritability/Agitation

What do we learn from these Case Studies? A variety of medical interventions worked for these children Each child benefited from a different type of intervention Autism is a “Spectrum Disorder”…children with Autism are very different from each other! Will these interventions work for your child?  We simply don’t know!

Next Steps in the Medical Treatment of Autism We need to do studies that show changes across groups of children  Exp: all children exposed to MB12 improved  This is difficult (if not impossible) because the children are all different from each other!

Therefore, we need to find PHENOTYPES of Autism  What type of child does well with MB12?  Which children benefit from chelation?  Who needs a course of HBOT?

What you can do as a parent Look for biomarkers that indicate what medical treatment your child needs Understand the lab results your physician orders Try one intervention at a time Measure the change in behavior with each intervention Stick with a plan! DO ABA! IT WORKS FOR ALL KIDS

What is Applied Behavior Analysis ABA is based on the principles of

Operant Conditioning Theory: “Human Behavior is affected by events that precede it (antecedents) and events that follow it (consequences)” Change these events…change Behavior!

What does that mean? In ABA, we manipulate reinforcers in order to increase functional and adaptive behaviors, and decrease challenging behaviors. We give reinforcers when a good (adaptive) behavior occurs We remove reinforcers when a bad (challenging) behavior occurs

Reinforcers make the world go round! If a child wants a toy and he cant say “I want that toy”, what do you think he will do to get the toy? He will grab, hit, or do what ever it takes to get the toy! When he hits and gets the toy, he just gained access to a reinforcer for hitting…he got the toy! From now on, he will learn to hit in order to get toys!

Replacing Challenging Behavior with Appropriate Behavior Johnny wants a Johnny sees a toy! He doesn’t Toy how he wants know to ask nicely!

Johnny hits Johnny asks for his sibling toy andThe grabs the toy

Johnny gets Johnny gets the theand toylearns and toy learns that that asking is hitting is Effective! effective!

What if Johnny does NOT get the toy when he hits And We teach him to ask nicely when he wants a toy?

Everything we do is to Get good stuff or Avoid bad stuff! Give

Remove

Good Stuff + ReinforcementResponse Cost Extinction Behavior Behavior Bad Stuff Punishment Behavior

- Reinforcement Behavior

What behavior do we want to change? Deficits     

Language Play Social Skills Theory of Mind Executive Functions

Skill Repertoire Instruction

Excesses  Self Stimulatory Behs  Maladaptive Behs • Tantrums • Aggression • Noncompliance

Behavior Management

The Secret to successful ABA The key is to teach appropriate skills! If a child has appropriate skills, and they are easy to do, he will not engage in challenging behaviors! We cannot simply “extinguish” challenging behaviors without replacing them first, with appropriate skills!

THE CARD MODEL Applied Behavior Analysis or The CARD Program Skill Repertoire Building

Behavior Management

Curriculum Assessment

Defining Problem Behavior Functions of Behavior

Teaching Paradigm

DTT

Functional Behavioral Assesment FluencyBased

NET

Indirect

Teaching Procedures

Prompting/ Fading

Discrimination Training

Shaping

Descriptive

Function-Based Treatment

Chaining

Replacement Behavior

Evaluation of Tx Effectiveness (Data Collection & Analysis)

Generalization & Maintenance

Antecedent Modifications

Experimental

Emergency Interventions

Consequence Manipulations

Shaping Knowledge Through Individualized Life Learning Systems (SKILLS)

What is SKILLS? E-Learning  Trains “how to” do ABA (the techniques)

SKILLS Index  Every child is different…what do I teach my child?  Assesses child’s known and unknown skills through questions directly tied to CARD I Curricula

CARD I Curricula  Provides “what to” teach

Skill Repertoire Instruction Discrete Trial Training Prompting Shaping Chaining Reinforcement Errorless Learning Natural Environment Training Fluency Based Instruction

This is HOW we teach skills…This is the CARD E-Learning Modules

What skills does my child need?  Skills Assessment • What skills does my child have?

• Standardized global assessments  IQ  Language  Adaptive

• CARD Assessments     

Language Play Executive Fxns Gross Motor Adaptive Skills

Social Skills Social Cognition Self-Help Fine Motor Academic Skills

• Curriculum designed to meet child’s needs

The CARD Curriculum School Skills

Executive Cognition Functions

Language

Play

Social Skills

Adaptive

Motor Skills

The CARD Curriculum

Language

By Emerging Age and Verbal Operant:

0-11 mos. Choices Listen to/Tell a StatementBody Parts Fast Mapping Story Statement Locations Following Functions 4:0-4:11 yrs. Instructions Negation Objects Describe by Gestures Plurals Opposites Category/Feature/ Making Recalling Events Prepositions Function Requests Sound Speed & Pronouns Phonic Same/ People Duration 2:0-2:11 yrs. Different Sound Syllable Adverbs StatementDiscrimination Segmentation AttributeQuestion Verbal WhObject What Goes With Imitation Discrimination Conditionality3:0-3:11 yrs. 5:0-5:11 yrs. Yes/No Deliver a Observational 1:0 – 1:11 yrs. Minimal Pairs Message Learning Actions Same/Different Features Syntax Asking for Sequences Gender Information Sound Changes I Have/ISee Categories

The CARD Curriculum

Play

Features of a Comprehensive Play Skills Program  Modeled after the development of

play skills in

typically developing children Breaks down each type of play into its own systematic and comprehensive program Sequential format Programs may be used individually, concurrently, or cumulatively

Play Curriculum

Play

Domains Sensorimotor Play Task Completion Play Beginning Play Initiating and Sustaining Play Block Imitation Structure Building Constructive Sand and Water Constructions Play Clay Constructions Arts and Crafts

Audio and Video Play Computer Play Electronic Play Video Games

Early Social Games Read-to-Me Books & Nursery Rhym Interactive Music and Movement Play Treasure Hunt Card and Board Games Locomotor Play Peer Play

Pretend Functional Pretend Play Play Symbolic Play Imaginary Play Sociodramatic Play

Adaptive Curriculum Personal Feeding Toileting Undressing Unfastening Dressing Preventing Spread of Germs Bathing Fastening Teeth Care Hair Care Nail Care Health Care

Domestic Adaptive

Pet Care Setting & Clearing Table Telephone Skills Tidying Meal Preparation Cleaning Gardening Laundry School Backpack Prep Making a Bed

Safety Community Shopping Restaurant Readiness

Safety Awareness Safety Equipment

Motor Curriculum Motor

Oral Oral Motor

Visual Fine Sitting Standing Walking Running Jumping Hopping

Gross

Ocular Motility Binocular Vision Skills Visual Perception

Hand Skills Coloring Pre-Handwriting Drawing Cutting with Scissors

Crawling / Creeping Riding Foot-Propelled Vehicles Rolling Over Rolling / Throwing / Dribbling Stairs and Climbing Riding a Tricycle / Bicycle Balance Beam Swinging a Bat / Racquet / Paddle Kicking Physical Education Readiness Catching

Visual Form Constancy Match the picture on top with one of the four choices. 1.

2.

3.

4.

Motor

Visual Form Constancy Motor

What is added to the first picture to make the second picture? 1.

First Picture

Second Picture to

2.

First Picture

Second Picture to

3.

Second Picture

First Picture

to

Visual Figure-Ground Discrimination

Motor

1.

How many times is the number 8 in the above picture? 7 times 10 times

8 times

5 times

2.

How many times is the number 6 in the above picture? 10 times 4 times

5 times

1 time

3.

How many times is the number 9 in the above picture? 9 times 3 times

15 times

2 times

Visual Closure Motor

Draw the missing parts of the picture on the right. Color the picture on the left. 27.

Left

Right

28.

Left

Right

The CARD Curriculum Math

School Skills

Number ConceptsLanguage Arts 1 Rote Counting Language Arts 2 Reading Reading Numerals Visual Discrimination of Symbols Writing Manuscript Numeral Comprehension Reciting Alphabet Science Printing Symbols Ordinal Position Physical Education Personal Data Numerals in SequenceUppercase Letters Lowercase Letters Lowercase Letters Addition Word Recognition History Uppercase Letters Subtraction Orally Letters in Sequence Advanced Counting ReadingSocial Studies Reading Comprehension Letters Dictated Money Book Topography Simple Sentences Time NonAcademic Story Comprehension Quality of Printing Story Summarizing Skills Text Comprehension

The CARD Curriculum

Cognition

Cognition:  Meta-cognition: Identifying your own …  Social Cognition: Inferring others’…

Emotions Thoughts Knowledge Desires Beliefs Intentions

Classic Test of Social Cognition “Sally-Anne” or False-Belief Task

Cognition

Where will Sally look for her ball? Where does she think her ball

“Typical” Meta and Social Cognitive Development

Cognition

First few months: Sense of Self 9 months: Joint Attention / Social Referencing 15 months: Pretence 18 months: Desire / Intention 2 years: Emotion 3 years: Knowing / Thinking 4 years: Belief / False-Belief 5 years: Intention – Accident vs. Purpose

Cognition Curriculum

Cognition

13 Lessons

Physical Detecting SarcasmStates

Intentions Deception

Beliefs Thinking Knowing

Emotions Cause & Effect Senses

Sensory Perspectiv e Taking Desires Preference s

Social Skills Curriculum

Social Skills

Social Language Greetings and Salutations Non-Vocal Social Behavior Social ID Questions Eye Contact Prosody Non-Vocal Non-Vocal Imitation Regulating Others Body Language & Facial Expressions Absurdities Social Behavior Conversational Audience Gestures to Regulate Social Interaction Figures of Speech Social Social Interaction Physical Context of Conversation HumorAbsurdities and Jokes Language Apologizing Listening to Conversation What’s Wrong? Assertiveness Initiating Conversation Compliments Joining Conversation Cooperation & Negotiation Maintaining Conversation Group Group Related Skills Social Gaining Attention Social Skills Repairing Conversation Related Responding in Unison Introductions Interaction Transitioning Topics of Conversation Group Discussion Skills Levels of Friendship Ending Conversation Sharing & Turn Taking Social Rules SelfLending Esteem & Borrowing Compliance Dealing with Conflict Social Following Rules Positive Self-Statements Self Esteem Rules Community Rules Social Context Winning & Losing Social Politeness & Manners Constructive Criticism Responding to Social Cues LearningContext Through Observation

The CARD Curriculum What is Executive Function?  Process that underlies goal directed behavior Goal Directed Behavior Involves… Visualizing situation Identifying desired objective Determining plan to meet objective Monitoring progress to goal Inhibiting distractions

Executive Functions

Executive Functions Curriculum Inhibition

Planning

Waiting, Physical / Motor, Vocal, Inhibition Pencil / Paper

Task / Social Goal Setting, Previewing, Task Initiation, Monitoring Progress, Time Management, Planning Organizing Materials, Using a Planner, Self-Organization

Meta-Cognition MetaMeta-cognitive Planning, Cognitive Self-Evaluation, Meta-memory, Planning Self-Monitoring of Attention, Emotions, Reinforcement Control, Study Skills, & Flexibility

EF

Flexibility/ Set-Shifting

Executive Functions

Non-Social, Social, Flexibility Social –Cognitive, Attention Situational Social Orienting, Joint Attention, Sustained, Divided, & Alternating Attention, Determining Saliency, Attention Depth of Processing, Paraphrasing, Task Persistence

Problem Problem Solving Solving Non-Social, Social

Memory Associative, Memory

Visual, Spatial, Auditory, Episodic, Working

Children’s Color Trail Test

Stroop Activities

Summary A good ABA program requires good assessment to determine exactly what your child needs to learn! A good ABA program needs a lot of hours! Don’t do 5 hours of ABA when 40 hours are recommended! This is like taking 5 mgs of a drug that has shown to be effective at 40 mgs! It wont work!

A 4 year progression Year 1:  Child entering at age 2-3  25 hours per week building to 40 hours  Emphasis on • Building a relationship with child • Replacing challenging behaviors with functional communication  Mands (Requests)  Tacts (labels)

• Receptive identification (objects, actions, body parts, colors, shapes) • Receptive instructions • Verbal and Non-verbal Imitation • Identical Matching • Play Skills (toy play) • Adaptive Skills (toilet training) • Fine and Gross Motor • Dietary restrictions/medical compliance

Allocation of Hours 40 30 20 10 0

Year Year Year Year 1 2 3 4

Home-based

School-based

A 4 year progression Year 2:  Child age 3-4  40 hours (in home with partial transition to school)  Emphasis on • Building Expressive Language  Objects, Actions, Attributes, Prepositions, Pronouns  Categories, Functions, Occupations, Locations

• Beginning Conversation  Intraverbals  Reciprocal Statements  Asking Questions

• Developing Observational Learning  I See  Sequences  Tell me about/Describe

• • • • • • •

Emotion Recognition Inferring others desires Play Skills (functional pretend, symbolic, imaginary) Adaptive Skills (dressing, grooming, feeding) Fine and Gross Motor Sharing and Turn taking Attention (dual and divided)

Allocation of Hours 40 30 20 10 0

Year Year Year Year 1 2 3 4

Home-based

School-based

A 4 year progression Year 3:  Child age 4-5  40 hours (20 hours at home; 20 hours at school)  Sample Programs • Advanced Language Concepts  Pragmatic Language  Maintaining Conversation (topic initiation, repair, maintenance)

• Meta and Social Cognition  Identifying and Managing own emotions  Understanding other’s Perspectives, Knowledge and Beliefs  Inferences

• Executive Function    

Attention Saliency Flexibility with Routines Inhibition and Self Monitoring Planning

• Social Skills  Levels of Friendship  Recognizing Social Cues

• • • •

Problem Solving Play Skills (peer play dates) Adaptive Skills Fine and Gross Motor

Allocation of Hours 40 30 20 10 0

Year Year Year Year 1 2 3 4

Home-based

School-based

A 4 year progression Year 4:  Child age 5-6  40 hours (10 hours at home; 30 hours in school and fading services)  Emphasis on • Teacher and Parent training • School Skills  Listening and Reading comprehension  Math and Problem Solving

• Advanced Social Skills  Detecting Sarcasm  Understanding Deception  Group Skills

• Continued Self Regulation  Self Esteem and Confidence  Task and Social Planning

Allocation of Hours 40 30 20 10 0

Year Year Year Year 1 2 3 4

Home-based

School-based