Effectiveness of everyday activities-based protocol for autism and developmental disabilities

¶ … Activities to Reduce Inappropriate Behaviors Displayed by Children With Autism and Other Developmental Disabilities

The purpose of this dissertation study is to test the effectiveness of an everyday activities-based protocol (Holm, Santangelo, Fromuth, Brown & Walter, 2000) for managing challenging and disruptive behaviors of 13- to 23-year-old residential students (male and female) with Autism who live at Melmark Homes, Inc., of southeastern Pennsylvania, and attend school or adult day programs. Applied behavior analysis and a focus on everyday occupations (activities) will be combined during the intervention phase. Reinforcement will be for subtask completion and duration of participation, NOT for absence of target maladaptive or disruptive behaviors. Behavior analysts, however, will document the frequency/duration of the target behaviors during each condition. Interventions will occur daily, Monday through Friday. A single-subject, multiple-baseline, across-subjects design with nine subjects will be used to evaluate change in behaviors under alternating conditions. Data will be analyzed using graphical, semi-statistical, and statistical techniques, including celeration lines, slopes, 2 standard deviation bands, and the C-statistic. The projected outcome of the study is the validation of an activities-based protocol to enable greater participation of individuals with Autism in everyday activities (WHO, 2001), and in their communities, be they residential or non-residential (home-based) communities.

Use of Everyday Activities to Reduce Inappropriate Behaviors Displayed by Children with Autism

Historically, documented disruptive behaviors displayed by residential students diagnosed with autism and other developmental disabilities include noncompliance, physical and verbal aggression, inappropriate verbalizations not characterized as aggression, poor social skills, as well as deficits in attention to task (Green, 1996; Luce, 1981; Maurice, 1996). These behaviors require residential treatment and preclude participation in community based activities, (Luce, 2004). Educators generally agree that deficits in academic skills result from a decrease in on-task behaviors because of disruptive off-task behaviors (Skinn, Ramsey, Walker, Stieber, & O'Neill, 1987).

Frequently used techniques to decrease these disruptive behaviors include reinforcers such as verbal praise, token economies, time out, and self-contained classrooms. Autism affects one in 1,000 individuals in the United States (World Health Organization, 2001) and warrants further investigation to examine the use of daily activities to decrease these inappropriate behaviors. This quantitative dissertation study will examine the effectiveness of an everyday activities-based protocol (Holm, Santangelo, Fromuth, Brown & Walter, 2000) for managing challenging and disruptive behaviors of 13- to 23-year-old residential students (male and female) with Autism and other developmental disabilities to reduce two out of three inappropriate behaviors as identified by residential staff.

Purpose

The purpose of this quantitative dissertation study is to test the effectiveness of an everyday activities-based protocol (Holm et al., 2000) for managing challenging and disruptive behaviors of 13 to 23-year-old residential students (male and female) (dependent variable) with autism and other developmental disabilities who live at Melmark Homes, Inc., of southeastern Pennsylvania, and attend school or adult day programs. Applied behavior analysis and a focus on everyday occupations (activities) (independent variable) will be combined during the intervention phase. Reinforcement will be for subtask completion and duration of participation, not for absence of target maladaptive or disruptive behaviors. A single-subject, multiple-baseline, across-subjects design with 50 subjects will be used to evaluate change in behaviors under alternating conditions. Data will be analyzed using graphical, semi-statistical, and statistical techniques, including celeration lines, slopes, 2 standard deviation bands, and the C-statistic.

Research Question

Will participation in Activities of Daily Living (ADLs) reduce or extinguish inappropriate behaviors displayed by individuals with autism or other developmental disorders who currently reside in residential facilities?

Significance

Clinically significant behavioral changes in this area have the potential to lead to the expansion of residential programs, implementation of new programs, and the identification of, and access to, additional community funding resources for curriculum improvement and development; in addition to the development of more comprehensive community-based programs. The proposed dissertation study replicates the results found by Holm et al. (2000), which successfully combined behavioral and occupational therapy interventions with dually diagnosed subjects in community living arrangements (CLA)/school environments. Should a study such as this be successful, a full protocol can be developed for residential staff so that they too can be taught how to break down everyday tasks into manageable units so that residents with autism are able to increase their participation in everyday activities at school and in their communities whether they are residential or non-residential (home-based) living communities (WHO, 2001).

When evaluating community-based programming for individuals with Autism and other developmental disabilities, community, school, and healthcare leaders, must utilize data that is not only clinically significant but data that will drive cost effective programming to ensure the appropriate utilization of private and governmental financial resources (McConnell, 2004). The study will have significance to the consumer community because of the intervention's potential to enable greater participation of individuals with Autism in lived in environments. The study will have significance to the care-giving community because it promotes a novel approach to care-giving, using an intervention that combines a behavioral approach with enabling of everyday activities. To community healthcare leaders, this reduces the financial resources needed for community-based programming (WHO, 2001).

Review of the Relevant Literature

Background and Overview. Recently, autism has emerged as a major public health concern in the United States (Curran & Newschaffer, 2003). Autism is a spectrum disorder that encompasses many labeled disorders such as autism, pervasive developmental disorders, and Asperger syndrome (Jacobson, 2000; Baker & Welkowitz, 2005). Autism as a condition was first described by Leo Kanner in 1943 (Keane, 2004; Filipek et al., 1999), and previous estimates concerning the incidence of autism are now generally believed to have been too low (Fombonne, 2003; Crotty, Dadds, Ferguson et al., 2001). In fact, Richard L. Simpson (2004) emphasizes that "Autism can no longer be considered a low-incidence disability; the condition occurs with far greater frequency than ever considered imaginable! At the same time, however, it is obvious that autism is not a 'new' condition, but rather one that professionals and parents have recognized over the course of history, including before the time that Leo Kanner (1943) stamped the disability with its name" (p. 135). In his book, Behavioral, Social and Emotional Assessment of Children and Adolescents, Kenneth W. Merrell (1999) reports that "Leo Kanner, a pioneer in the study of what is now called Autistic Disorder, first described 11 children in 1943 who fit this general diagnostic picture" (p. 279). Kanner noted that the fundamental disorder of autistic children concerned their "inability to relate themselves in the ordinary way to people and situations from the beginning of life," and that a characteristic of this disorder is an aloneness that "disregards, ignores, shuts out anything that comes to the child from the outside" (Kanner, 1943, p. 43). This syndrome was described Kanner as "early infantile autism" because the tendency to display these characteristics seemed inborn and present from birth (Merrell, 1999, p. 279).

Today, autism is a term used to describe the entire spectrum of conditions called pervasive developmental disorder (or PDD) (Grandin, 1992; Cash, 1999; Boer & Dunn, 1992). Autism involves a wide range of social interaction and communication skills that can adversely affect the autistic individual's ability to function in many settings (Ammerman & Hersen, 2000). While the causes of autism also remain unclear, but there is growing evidence of a genetic component (Albertine, 2000; Rutter, 2000; Hetherington, Plomin & Reiss, 1994); however, environmental influences have also been shown to have an effect on the incidence of autism (Hastings, 2003; Blacher, Lardieri, & Swanson, 2000). The medical and chromosomal findings to date have also suggested genetic heterogeneity (Albertine, 2000).

Some major characteristics and associated features of the Autistic Disorder as set forth in the DSM-IV as presented by Merrell (1999) include:

Onset before age 3 years

Markedly impaired communication and social interaction

Markedly restricted repetitive stereotyped behavior

Prevalence of 2 to 5 cases per 10,000

More common among males than females

Often associated with mental retardation (Merrell, 1999, p. 279).

The common indications of autism and other developmental disabilities include deficiencies in social relationships and interaction, diminished ability to communicate, and abstract thought, as well as a limited range of interests and activities (Mayes, 2003; Coats, Feldman & Philipott, 2003). Autism may cause only slight limitations in daily activities or more severe limitations requiring intensive, life-long support (Dawson, 1996; Maguire, 2000). Some of the symptoms of autism include varying levels of impairment in interpersonal skills, emotional or affective behavior, and intellectual functioning; one of the most pervasive characteristics of the disability, however, is a delay or impairment in the ability to produce and respond to language (Shoen, 2003). In fact, a number of children with autism do not develop speech and other children with the disorder frequently exhibit unusual speech patterns such as echolalia, or the repetition of what has been heard. Further, the tone of their speech is usually flat and unexpressive. Finally, language difficulties are generally exacerbated by the social impairments that are associated with the autistic condition. Such language impairments are termed "secondary language impairments" to contrast them from "primary language impairments": "A primary language impairment is one for which there is no obvious cause. A secondary language impairment is one that can be explained in terms of another condition experienced by the child -- cerebral palsy, autism, hearing loss, etc." (Balkom & Verhoeven, 2004, p. 401). Shoen reports that children with autism frequently are unresponsive to others, generally fail to make eye contact, and tend to miss social cues such as a person's facial, verbal, postural, and gestural responses. Beyond these areas of difficulty, though, there exist other common disturbances such as stereotypic behaviors, self-stimulatory behaviors, self-injurious behaviors, repetitious actions, preoccupation with select objects or topics, aggression, inflexibility in routines, and over-sensitivity to sensory stimuli which are discussed further below.

Autism is a developmental disorder that is usually identified before 3 years of age. Strange behaviors tend to appear early in the child's life and diagnosis of the condition today has been expedited by more public awareness of the disability (e.g., popular cinema such as Rain Man), which may account for its higher incidence compared to past years. This is certainly a positive outcome of such attention, but the inaccurate portrayal of the disability can also result in public misunderstanding about the condition. For instance, only a small percent of individuals with autism possess the types of unusual skills exhibited by "Raymond" in Rain Man, such as a keen card-counting ability (Shoen, 2003). The existence of extraordinary drawing ability in the presence of retardation and autism, and in the absence of any explicit instruction, though, certainly suggests a biological, brain-based explanation for the condition (Ericsson, 1996).

In her book, The World of the Autistic Child: Understanding and Treating Autistic Spectrum Disorders, Bryna Siegel (1998) reports that the use of nonverbal intelligence as a way of estimating an autistic child's general level of mental development is not a perfect indicator, but it does provide clinicians with a benchmark for separating a number of the effects of mental retardation from the condition of autism; nevertheless, Siegel points out that the vast majority of autistic children have some degree of mental retardation associated with their autism, so it is important to find a way to measure it separately from the symptoms of autism. "This is because delays in development due to autism or PDD and delays in development due to mental retardation are not always treated in the same way," Siegel notes, but "By using the child's level of nonverbal IQ (nonverbal mental age) as a baseline, we are essentially asking 'How does this child's behavior in each autistic symptom area compare to what a child should typically be able to do at this mental age?'" (p. 17). In this regard, studies have shown that the everyday adaptive functioning of individuals with autism is typically more impaired than their intellectual functioning (Brown, 2004). Having established a general focus on the child's nonverbal mental age (which a professional obtains through a combination of intelligence testing, observations of the child, and parent interviewing), it is then possible to assess the child for the presence of autistic symptoms; Siegel provides the following definitions of autistic disorder and PDD to help in this regard:

Autistic Disorder. In order to be diagnosed as having autistic disorder, using the DSM-IV criteria, a person must have positive signs on six out of the twelve criteria. At least two of the criteria met must reflect difficulties in social development; two criteria must be met in the area of communication; and at least two criteria in the area of atypical activities and interests must also be met.

Pervasive Developmental Disorder, Not Otherwise Specified (NOS). If the child has a less severe form of the behavior described in a criterion, that may contribute to a diagnosis of PDD, NOS. If no criteria is met in the category of atypical activities and interest (as shown in part C in Table 1 below, but the child does show a variety of signs in the categories of social and communicative development, the diagnosis of PDD, NOS is also used.

Table 1. DSM-IV Criteria for Autistic Disorder and Pervasive Developmental Disorder, Not Otherwise Specified (PDD, NOS)

To be diagnosed with autistic disorder at least one sign (each) from parts A, B, and C. must be present, plus at least six overall. Those meeting fewer criteria are diagnosable as PDD, NOS.

A.

Qualitative impairments in reciprocal social interaction:

1.

Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction.

2.

Failure to develop peer relationships appropriate to developmental level.

3.

Lack of spontaneous seeking to share enjoyment, interests, or achievements with others.

4.

Lack of socioemotional reciprocity.

B.

Qualitative impairments in communication:

1.

A delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime).

2.

Marked impairment in the ability to initiate or sustain a conversation with others despite adequate speech.

3.

Stereotyped and repetitive use of language or idiosyncratic language.

4.

Lack of varied spontaneous make-believe play or social imitative play appropriate to developmental level.

C.

Restricted, repetitive, and sterotyped patterns of behavior, interests, or activity:

1.

Encompassing preoccupation with one or more stereotyped and restricted patterns of interest, abnormal either in intensity or focus.

2.

An apparently compulsive adherence to specific nonfunctional routines or rituals.

3.

Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping, or twisting, or complex whole body movements).

4.

Persistent preoccupation with parts of objects.

Abnormal or impaired development prior to age three manifested by delays or abnormal functioning in at least one of the following areas:

(1)

Social interaction;

(2)

Language at used in social communication; or,

(3)

Symbolic or imaginative play.

Source: The Diagnostic and Statistical Manual, 4th Edition, American Psychiatric Association, 1994.

In some cases, clinicians will tentatively use PDD, NOS when a child is so young that many of the criteria are believed to be too difficult to see; however, this approach is problematic because other clinicians who are very experienced with young autistic children can tell fairly accurately from the early profile of symptoms that are met whether the child has autism or PDD, NOS. According to Siegel (1998), "This is because they understand what the earliest forms of autistic symptoms are. Using such early developmental guidelines, a clinician who is experienced with young autistic children can often tell if a child is autistic by a child's second birthday and sometimes sooner" (p. 18). The research to date has been unable to specify any single causation of autism; consequently, interventions for the disability have varied greatly.

Many individuals with global learning disabilities and individuals with autism or Asperger syndrome will benefit from social skills training (Bentham, 2003); however, Schoen (2003) cautions that in spite of the wide range of interventions that have been developed for children and youth with autism that incorporate strategies from psychoanalytic, medical, educational, and behavioral perspectives, the sheer multiplicity of the available interventions for parents and/or guardians to consider is overwhelming and confusing. Further, researchers and clinicians continue to debate the efficacy of one treatment option compared to other. Some experts make optimistic claims to cure the disability, while other professionals focus on remediating a specific behavior or building a particular skill (Shoen, 2003). In the final analysis, caregivers and educators are confronted with the problem of choosing the intervention that offers the best potential for a successful response and outcome. Some of the current techniques being used to help moderate inappropriate behaviors displayed by children with autism and other developmental disabilities are discussed further below.

Interventions Currently Being Used for Moderating the Inappropriate Behaviors Displayed by Children with Autism and Other Developmental Disabilities. While the vast majority of research on autism and developmentally disabled children has focused on identifying causes and effective treatments, there is a glaring need for studies of ways that parents can best cope with the rigors associated with raising a special needs child (Finn, Johnson, Paul & Watson, 2001). According to Symon (2001), parents with a special needs child typically require a number of specialized resources; however, securing these resources can place extra stress on parents. Further, autistic and developmentally disabled children may require specialized treatment procedures, medications, or adaptive equipment; frequent hospital visits; or restricted diets (Carter, Delcarmen-Wiggins, 2004). In this regard, "Children with developmental disabilities may require special education resources or individualized instruction," Symons notes, and "To obtain these necessary services for their children, parents may face excessive financial burdens and stress" (p. 160). Despite these constraints, engaging the parents and other caregivers in the treatment process in a meaningful way to ensure that these children are provided with settings that are as normal and routine as possible remains an integral part of developing an effective treatment modality.

According to Shoen (2003), some of the treatments that concentrate on emotional disturbances related to autism are founded on the psychoanalytic approach. "Holding Therapy, for example," she says, "attempts to build a bond between the child with autism and the parent/guardian. The caregiver is advised to hold the infant very closely and tightly as s/he speaks in a comforting tone, even when the child tries to escape the embrace" (p. 126). Still another approach that emphasizes relationship building is the Son-Rise program (Kaufman & Kaufman, 1998). In this approach, parents and caregivers repeat the actions of the child in an environment that is not distracting or stimulating (Shoen, 2003). Because children with autism may not engage in reciprocal social behaviors, the majority of the caregiver/child time will most likely be invested in attempting to enter the child's world and provide unconditional love and acceptance in a meaningful way; however, the difficulty of formulating effective interventions for these children and others like them are profound. According to Schoen, there are there primary factors that contribute to this difficulty:

1.

There is a guilt-based underlying assumption that the family relationship is problematic;

2.

The intensity of the treatment may not be feasible for many families with other work and parenting demands; and,

3.

The treatments are highly invasive with close and on-going proximity to the child (2003).

Other treatments have emphasized a physiological basis for the autistic condition and resort to medical interventions; in these cases, medications used for treating individuals with autism range from tranquilizers, anti-depressants, anti-anxiety drugs, and stimulants to anti-convulsants (Heflin & Simpson, 1998); however, more natural, dietary treatments are also recommended. For example, Rimland (1999) strongly advocates the use of high dosage vitamin B6, magnesium, and dimethlglycine. The concerns regarding such natural and prescribed remedies extend across a wide range of issues, but there remains a paucity of data available, though, concerning the side effects of these treatments; new pharmacologically based therapies for this population also continue to lack supportive research and study. Questions also remain concerning the proper dosages for young children, and what adverse effects can result from the combination of biological treatments. Whatever approach is selected, careful clinician monitoring of such interventions is clearly required to ensure the health and welfare of the child (Shoen, 2003).

Another treatment modality for this population centers on educational options and is broader in scope. Alternatives for consideration in this category of interventions focus on the placement of the child. A continuum of educational services is available from a segregated special education program to a fully inclusive placement in general education classes with support services. A highly individualized program is required to meet the specific needs of the child. Of particular concern is the issue of the onset of treatment. Time and again, early intervention programs that were initiated before the age of 5 years of age have been strongly related to progress (Shoen, 2003). Indeed, the provision of effective support services for families of children with autism represents an area of growing concern. According to Symon (2001), children with autism are already at high risk for poor clinical outcomes: "Individual and system-level risk factors that are associated with having autism could result in poor outcomes; however, "Positive behavior interventions that address individual and family needs could potentially ameliorate these risk factors" (p. 160). Positive behavior interventions may sound more palatable, but like negative reinforcers, the purpose of this final treatment approach is behavioral in nature. This alternative focuses on increasing appropriate behaviors and decreasing inappropriate behaviors.

According to Bruder, Dunst, Hamby, Mclean, Raab, Trivette (2001), not all life experiences have similar features nor do they all have similar effects on learning and development. "Everyday activities that invite and encourage child participation," they say, "would be expected to produce positive developmental consequences, whereas everyday activities that hinder and discourage child participation would be expected to have negative developmental consequences" (p. 69). Therefore, in order for behavioral treatments to work, there needs to be an understanding of how children with autism use the stimulation around them to predict an appropriate response (Schreibman, 2000). This stimulus-response relationship attempts to build a connection for children with autism and other developmental disabilities. Applied behavior analysis, which emphasizes this relationship, has been reported by the Surgeon General of the United States to be the most effective way to treat autism (Rosenwasser et al., 2002). The stimulus-response alternatives are discussed further below.

Negative Reinforcers. While the term "negative reinforcement" may carry with it some serious adverse connotations, it is important for parents, caregivers, clinicians and others to keep in mind that "negative" does not necessarily equate to "punishment" or "discipline," but in many cases are rather simply attempts to modify the adult responses to stereotypic behaviors in autistic children. According to Dr. Bryna Siegel (2003), "The most common method of negative reinforcement used with children with autism is to ignore the child. Ignoring is the act of turning your back on a manipulative behavior that was previously successful at obtaining a desired end" (p. 275). The concept behind this approach is that if the undesirable behavior is no longer successful because no one sticks around to respond to it, then it becomes ineffective; however, developmentally disabled children in general and for those with autism in particular, this technique only works occasionally and there are two instances in which ignoring is in inappropriate approach for the developmentally disabled. These are:

1.

Ignoring Endangering Behaviors. Clearly, it is important to recognize negative behavior that is dangerous to the child, to someone else, or to property. For example, Siegel points out that:

If Amalia had kicked her baby sister's high chair while her baby sister was in the high chair, Dad, who had been instructed to ignore tantrumming, would have had a much harder time doing so. Probably, he would have taken Amalia out of the kitchen and tried to distract her in some way. This would have in essence said that 'if you tantrum, someone will intervene and offer you something that will make you happier than you are at this moment.' That will have essentially provided a low-level reinforcer. If Dad had taken baby sister out of the kitchen with him, Amalia might have "ruined" the ignoring by accelerating to the point of trashing the high chair. "Once the undesirable behaviors have risen to the level that the child realizes won't be ignored, like hurting others or property, it is too late to use ignoring to eliminate the behavior, and more powerful deterrents are needed. (Siegel, 2003, p. 276).

2.

Ignoring and self-injurious behavior SIBS. A good example of a behavior you don't want to ignore is a self-injurious behavior (SIB). Some SIBs are designed to manipulate parental behavior, as with the child who bangs his head and then looks to see if he is about to get the gum he wants from his mother's purse. This rapidly becomes a complex situation as the parent finds herself torn between setting firm limits and preventing real harm. Educators who are in this situation are also trapped between establishing firm limits and possibly having to file an incident report (Siegel, 2003).

The majority of SIBs most likely begin as an "overflow" response when the child is already agitated. According to Siegel, "Universally, there is great similarity in SIBs among children with autism, with characteristic biting of the palm, the top of the hand between the index finger and thumb, or the wrist, or banging the forehead. (This does not mean the child learned a particular SIB from another child, but rather it's hardwired -- like thumb sucking)" (2003, p. 277). The baffling and complex nature of autism makes the formulation of an appropriate response problematic for parents and caregivers though, and it is entirely possible that techniques used with typically enabled children will not work the same way with autistic or developmentally disabled children, or even if they do, they may not work the same way more than once. Nevertheless, it is critically important that even during stressful periods with such children acting out in whatever manner that they take the time to mentally evaluate what effect their reaction may be on the child. Symon suggests that if parents and other caregivers fail to take the steps required to enter the autistic child's world, the child will be the one who suffers: "A lack of responding to the environment can lead to missed learning opportunities for the child" (p. 160). Unfortunately, the stress and fatigue that can affect a parent or other caregiver during these exchanges may make an effective engagement even more difficult. For example, Siegel points out that, "If at this moment of intense frustration and SIB, the parent responds to her own distress at the appearance of a SIB by giving the child whatever he is frustrated about so as to soothe him and deter the SIB, the parent is probably inadvertently reinforcing the SIB as an effective method of manipulating parent behavior" (2003, p. 278). From that point on, the SIB may manifest whenever the child is truly frustrated; however, as the child matures, the threshold for appearance of a SIB will likely become lower as it becomes more likely that the SIB will produce the desired effect (Siegel, 2003). Despite the problems associated with maintaining a watchful eye for opportunities for learning and crafting effective reinforcer responses, parents are of course in the best position to understand what is best for their own child. Parents have the opportunity to observe the autistic child around the clock, and they are in the best position to gauge what a response to a given stimuli might be; furthermore, studies have shown that parents of autistic children prefer positive reinforcers over negative ones in trying to mediate self-injurious behaviors. According to Berkson (1993), "Parents often have clear ideas about appropriate and inappropriate educational procedures and treatments for their children. For instance, parents of autistic and severely retarded children prefer nonpunitive procedures in the treatment of self-injurious behaviors" (p. 272). It is the law of the land in the United States that parents are responsible for participating in the educational planning for their children; nevertheless, there are a number of obstacles to this participation for the parents of autistic children, including a paucity of knowledge and a lack of skills by both parents and teachers, lack of confidence on the part of parents, their informal exclusion from discussions, and power struggles between parents and teachers (Berkson, 1993). On those occasions when parents do participate, though, they have typically expressed significant satisfaction with the school, the teacher, and the services received.

One of the problems associated with self-injurious behaviors in autistic children is the way in which these children understand the world around them, and how their fundamental thought processes will lead them to inappropriate and potentially dangerous conclusions about such behaviors. For example, the autistic child may come to understand the relationship between showing anger and getting his way and may get worked up to the point of self-injury with the secure understanding that it may bring an end to his frustration. Citing the case of a 130-lb., 10-year-old, "Rashid," who presented with a wide range of behavioral problems including banging his head when he was truly aggravated. Yet another behavioral problem with Rashid was overeating, a fact that further complicated the SIBs scenario because it introduced a multiplicity of values into Rashid's environment; however, a careful assessment of the interrelationship between these conflicting values helped this practitioner identify techniques that helped moderate Rashid's SIB behaviors.

Rashid was an obese child, and one of the things he really liked was corn chips. His parents had brought along a huge bag, hoping this would keep him calm during our testing. Rashid knew the corn chips were in his mom's backpack and made many attempts to extract them, but after we had discussed overeating and overdependence on corn chips as a behavior control tool, his mother would not give them to him. Rashid began banging his head. His parents became quite distressed, and his mother quickly reached for the corn chips. To test the hypothesis that this head banging was not pure aggravation but also manipulation, I sat on the floor next to Rashid, ignoring him but playing with a brassy, loud electronic train he'd been showing great interest in all morning. As I played, the head banging became intermittent, and Rashid surreptitiously crept on his belly toward me, whining but stopping for a bang or two along the way. Finally, he grabbed the train from me and began playing with it himself. The train was more interesting than the tantrumming that was being ignored. More importantly, the differential value between the train and the corn chips was not so great that a train in the hand was worth more than corn chips in the backpack (emphasis added) (Siegel, 2003, p. 277).

The learning curve with autistic children can be dramatically different from their mainstream counterparts, though, but give adequate time, it would appear that a consistent application of everyday activities serves to orient autistic children in a manner that helps them learn by keeping things relevant.

The importance of providing autistic and developmentally disabled students with appropriate learning opportunities has assumed new importance since the reauthorization in 1997 of the Individuals with Disabilities Education Act (IDEA). Based on these federal mandates, the individual states are required to provide early interventions in natural learning environments for children from birth to 3 years with disabilities or developmental delays. As a result, policymakers and practitioners at all levels have been faced with the need to incorporate a natural environment for such students; however, traditional service delivery models and approaches to early intervention and therapy have been found to be incompatible with this requirement (Batman, Mott & Wilson, 2004).

Traditional early intervention practices focus on teaching children discrete behaviors and skills in isolated settings. Unfortunately, the majority of the initiatives to date that have attempted to use natural environments as contexts for children's learning have focused on the where, but not the how, of service provision. According to Batman et al., "Natural environment enthusiasts make the case that early childhood intervention and therapy should be made meaningful and functional by being implemented not only in more natural environments, but also in the context of activities that are part of the everyday routines and experiences of children and families" (p. 110). Likewise, according to Bornstein and Lamb, "a very large proportion of our normal, everyday activities can be considered prosocial behavior. Although many of our everyday activities have beneficial effects on others, a much smaller proportion of them are undertaken with the intention of having these effects" (p. 387). Therefore, by recognizing the need for incorporating as many everyday activities and items into their repertoire of treatment alternatives, clinicians can identify those unique activities and items that best help such children make the mental leaps required to assimilate new information and place it into appropriate context.

For example, in their analysis, "Teaching Children with Autism to Prefer Books or Toys over Stereotypy or Passivity Stereotypy," Greer, Leonard, Nuzzolo-Gomez, Ortiz, and Rivera report that stereotypy is a common behavior found in children with autism; the authors define stereotypy as being "cycles of repetitive movements that have no apparent consequences for the individual who is emitting the responses beyond the movement itself" (p. 81). Some children with autism engage in inordinately high rates of stereotypy. A number of treatment techniques have been used to moderate such stereotypical behaviors with the majority of these being negative reinforcers/punishments such as physical restraint, overcorrection and even the use of electric shock. According to these authors, "Punishment procedures have been effective in decreasing stereotypy but often have limited maintenance of initial treatment effects" (p. 82). Although less prevalent in the growing body of research on autism and other developmental disabilities, positive approaches have increasingly been shown to have been successfully implemented to decrease stereotypical behavior in such children. Greer and her colleagues point out that these positive treatment approaches have included differential reinforcement of other behavior, spaced responding differential reinforcement of low rates, as well as teaching children functionally equivalent communication. These and other positive reinforcers are discussed further below.

Positive Reinforcers. In her book, Autism Spectrum Disorders: Identification, Education, and Treatment, Dianne Zager (2005) reports that, "Most human behavior is maintained by reinforcers called generalized conditioned reinforcers. Examples of these include attention, affection, approval, and tokens, such as points, stickers, and money" (p. 304). While money itself will clearly have no discernible value to an infant, as a child accumulates experiences in which money is exchanged for items having positive value, currency assumes a reinforcing value of its own. "Food is reinforcing when we are hungry," Zager says, "and a soft drink is reinforcing when we are thirsty. Unlike food and drink, generalized conditioned reinforcers are not dependent on a single deprivation state. They acquire reinforcing value by being paired with known reinforcers" (2005, p. 304).

Positive attention from others and social praise alone, though, may not function as sufficiently effective reinforcers for most children with autism; in order to successfully acquire reinforcing value, therefore, other visual and aural reinforcers must also be presented such praise, such as smiles, or gestures of affection (Zager, 2005; Rosner & Semel, 2003). The experts emphasize that these "extras" must be repeatedly paired with the delivery of tangible reinforcers, such as food, to assume the quality of value required to be effective with these children. According to Zager, "By repeatedly pairing praise with strong highly valued reinforcers, positive attention will gradually acquire value and sustain performance. Later, new items and events can become reinforcers by pairing them with these newly acquired secondary reinforcers" (p. 304). This technique has been shown to be effective with moderating the behavior of children with autism by bringing the same stimuli that control the behavior of typically developing children to bear on the developmentally disabled (Zager, 2005).

To determine the effects of introducing everyday items such as toys and books on the behaviors of autistic and developmentally disabled children, two experiments were conducted by Greer et al. with four such students; students were observed playing and the effect of these ordinary items on stereotypy and passivity were made. The first experiment consisted of a single preschool student who emitted frequent intervals of passive behavior and infrequent intervals of looking at books in a free play setting (Greer et al., 2002). Following systematic training sessions involving pairings of reinforcers with looking at books, the student engaged in looking at books significantly more than in his baseline in free play and decreased intervals of passivity. The second experiment involved a multiple baseline across three students; baseline data were followed by toy-play conditioning sessions run concurrently with free-play observations. In this instance, the two students who emitted frequent rates of stereotypy in baseline demonstrated significantly fewer intervals of stereotypy after toys were conditioned as reinforcers and toy play increased for all three students (Greer et al., 2002).

The importance of ensuring a sufficient amount of socialization in natural environments for children with autism and other developmental disabilities was the focus of a study by Kelly (2003), who reports that, "During the past two decades, researchers have documented that children who engage in social withdrawal and behavioral solitude in the presence of peers are more likely to experience socio-emotional difficulties" (p. 161). This study used a participant observation methodology to determine the effects of teaching play strategies to one child with autism and global delay on his cognitive development, academic progress, and social interactions with his disabled and typically developing peers. The author used a curricular model that integrated the components of structured teaching with developmentally appropriate practices to teach the 3-year-old child play skills in an integrated preschool setting. According to Kelly, "During the study period, scheduled observations in 20-minute segments were conducted four times a week, resulting in over 150 hours of direct observation. Observations were conducted during structured teaching, free choice play time, lunch, and small- and large-group activities" (p. 162). Historical records of the treatment sessions were developed by the teacher and supplemented with work performed y the child by using video and audio recordings, as well as accompanying anecdotal records. A content analysis methodology was used to identify emerging themes from the data transcripts, written observational records, and child work samples. According to Neuman (2003), content analysis is "research in which on examines patterns of symbolic meaning within written text, audio, visual or other communication medium" (p. 531). The themes that emerged from the content analysis were then organized into patterns of development in the child's interactions with toys and other students in the classroom, and provided Kelly with findings that were directly related to the research questions.

The results of this study showed that prior to teaching play strategies, the child routinely participated in unoccupied or solitary play, rarely engaging in productive play with objects or peers. Upon conclusion of the structured play skills treatment phase, the child had developed more complex play and social behaviors; further, he also participated in more open-ended play and was shown to be able to generalize those skills to new situations (Kelly, 2003).

There are also a number of assessment methods and procedures available that can help caregivers and clinicians assess children's participation in everyday settings and activities, including the ABC Matrix. According to Batman et al. (2004), "The ABC Matrix builds upon these approaches by addressing the need for contextually based assessment tools that assist practitioners in bridging the gap between assessment findings and the development and implementation of interventions in natural environments" (p. 111). The ABC Matrix approach is founded on the concept that "natural environments are not places, but the everyday routines, experiences, and activities occurring in different social and nonsocial contexts as part of family and community life" (Batman et al., 2004, p. 112).

Definitions of the ABC Matrix content areas are provided by Batman and her colleagues below:

Activity Settings. These are the everyday experiences, opportunities, or events that involve children's interactions with people and objects that provide them with a solid basis for learning about their own abilities. According to Batman et al., "Activity settings are those everyday activities that happen in the different places where children and families spend their time" (p. 112).

Interests. These are simply the child and family's likes or preferences. They are favorite toys, objects, people, or events that encourage engagement and participation in different activity settings. Interests encourage both expression of existing abilities and promotion of new learning. Assets are the abilities, strengths, skills, and capabilities used to participate in interactions with objects and people and which produce desired social and nonsocial environmental consequences and effects as part of and because of this participation.

Functional and Meaningful Activities. These are those interactions between children and their social surroundings in which children use a behavior purposefully to communicate, move, and interact with objects and people; however, the term also refers to those critical activities that are performed for the child or necessitate the participation of another person (e.g., bathing, dressing, eating).

Opportunity. This is the quantity and quality of experiences that takes place in activity settings that serve to promote increased social and nonsocial child participation in everyday activity; according to Batman et al., "Opportunity is the number of chances and the quality of those chances that children have in everyday activity. Opportunities set the occasion and promote participation in everyday activities" (2004, p. 112).

Participation. This term refers to the manner in which a child takes part in everyday activities. Participation is facilitated when caregivers pay explicit attention to opportunities that promote child behavior that is 1) conventional and 2) both socially and culturally acceptable. In other words, child participation is increased in ways that provide opportunities to learn, practice, and perfect abilities that permit a child to "fit" into his or her social and cultural groups and settings.

Possibilities. Finally, this term refers to new opportunities and ways of participating in everyday experiences. "Possibilities build on the child and family's existing interests and assets, current opportunities, and participation," Batman and her colleagues report, "resulting in new ways of interacting with objects and people, as well as increased frequency, intensity, and variety of opportunities" (2004, p. 112).

The advantages of this technique were demonstrated through a field test which indicated that all of the practitioners found that the ABC Matrix was simple to administer, featured a user-friendly layout and design, and provided useful information for effective treatment plan development. The practitioners who participated in the field test of the ABC Matrix indicated that the guiding questions were useful to them in determining the types of questions to ask and a number of the respondents reported being surprised at how much relevant information could be gathered in a relatively short time. In addition, the respondent practitioners reported that the information developed by using the ABC Matrix transcended that obtained from traditional assessments and observations; in fact, all of the field-test participants indicated that use of the ABC Matrix resulted in more detailed information about children's assets and interests than they previously had been able to identify.

In this regard, one practitioner stated, "I always included strengths in my assessment reports before, but it seemed like something extra that I was digging for just to put in the report. With the Matrix, the strengths really come alive and are an integral part of the process, not something extra that is just thrown in"; another practitioner pointed out that the ABC Matrix "really helped me focus on the whole reason we're working with kids -- to help them learn to do things and to fully participate in their family and community -- not just to identify what they can't do" (emphasis added) (Batman et al., 2003, p. 113). Finally, a number of the practitioners reported that using the ABC Matrix simply helped them remember to talk with a family about everyday routines, activities, and environments in which they participate.

The authors conclude that the ABC Matrix should be completed by one or more of the child's parents or other primary caregivers, with the participation of an early childhood practitioner when desired. Batman and her colleagues also suggest that the ABC Matrix represents a valuable addition to the tools available to clinicians for accurately assessing existing childhood functional information based on children's participation in the contexts of family life, community life, and early childhood programs. "The Matrix is easily usable by practitioners and parents as an assessment process focusing specifically on contextually-based learning opportunities," they add (Batman et al., 2003, p. 114). A copy of the ABC Matrix questionnaire is provided at Appendix A, and ample ABC Matrix questions are listed below.

Table 2. Sample ABC Matrix Questions.

Activity Settings

What does your child and family do every day or almost every day?

What are the those things that have to be done, such as meals, dressing, bathing?

What does your child and family do on certain days, weekends, or times of the week/year?

What are the special events in which your child and family participate?

What are the special activities or events as part of your child and family's life?

Child and Family Interests

What does your child and family choose to spend time doing?

What are your child's favorite toys, people, and events?

What are those things that are interesting or enjoyable to your child and family?

Child and Family Assets

What does your child and family work especially hard at doing?

What are your child and family especially good at doing?

What are your child and family's strengths, skills, and accomplishment?

Functional and Meaningful Interactions

What does your child do to get started in play?

What does your child do to keep play or an interaction with you or others going?

How does your child get what he or she wants?

How does your child get to where he or she wants to go?

Opportunities

What activities does your child get to do every day?

How often does your child get to do his or her favorite things?

Where are the places your child gets to do the things he or she likes and can do?

Who does your child get to play or interact with on a regular basis?

Participation

What does your child actually do during an activity that he or she likes to do and is good at doing?

What are the specific ways in which your child participates in interactions with objects and people?

Possibilities

What are the ways that the current opportunities and participation can be expanded?

What interactions and skills would you like your child to develop?

(Source: Batman et al., 2003, p. 113).

Using the ABC Matrix is congruent with the recommendations of Berkson (1993), who reports that the use of appropriate categories or dimensions to describe an individual child with autism allows parents and professionals to discern patterns in the child's behavior and to learn whether the child is similar to other children in important ways. "If it turns out that the child is similar to others," he says, "it may be that treatments that have been successful with these other children might also be successful in this case. Thus, the use of appropriate descriptors allows grouping of children so that prevention and treatment of their handicap becomes possible" (p. 42). Having developed an appropriate assessment of the child's everyday life and relationships, it becomes easier to identify what normal objects, patterns and other factors in the child's life will make relevant learning opportunities (Tager-Flusberg, 2000).

While parents are clearly in a better position to discern patterns in behavior that will help the clinician identify opportunities for introducing everyday activities and items into the autistic child's world, the fact remains that autistic children react differently to the physical proximity of an adult, some of them are reluctant to be touched. According to Alvin and Warwick, "This has to be dealt with before any secure relationship can be established between the therapist and the child" (p. 10). These authors suggest that to accomplish this level of rapport is difficult, it is not impossible and they recommend the use of music therapy to help establish a bond between therapist and the autistic child:

Musical activities can follow a general pattern of social development, according to the child's maturity and ability to communicate rather than to his musical achievement. He may begin on his own, sing or play an instrument, or in a duet, sing with his mother or play with his teacher. Then I can try to make him join a larger group like a trio, a band, or an orchestra. Such steps can follow the gradual musical development of an autistic child and help him to integrate socially, provided that he can respond to a musical common denominator such as speed or a rhythmical pattern which unites the members of the group. (Alvin & Warwick, 1991, p. 27).

Finally, based on their investigations of children and everyday situations and objects, Dunst, Hamby, Trivette, Raab, and Bruder (2000) concluded that:

1.

Children are more likely to engage in activities in which they are interested and in which they use and build on existing assets;

2.

Learning is enhanced when children engage in meaningful activities in their natural environments;

3.

Participation in activities increases when children have ample opportunities to engage in interactions that support and strengthen their abilities in naturally occurring ways in everyday life opportunities; and

4.

Children are more likely to develop and perfect their interactive competencies with people and objects when they have numerous opportunities to engage in interactions that support and strengthen existing and emerging abilities in naturally occurring ways in everyday life.