CARD Speaker at COCO's on 2/28/06

Presentations: Doreen Granpeesheh PhD.

Dr. Doreen Granpeesheh, founder and Executive Director of the Center for Autism and Related Disorders, has dedicated over 25 years to the study and treatment of autism spectrum disorders. Through her research, curriculum development, and treatment implementation, Dr. Granpeesheh helped demonstrate the effectiveness of intensive, early Applied Behavioral Analysis intervention.

Dr. Granpeesheh earned her Ph.D. in psychology from UCLA in 1990, and was licensed by the Medical Board of California in 1992. She is a Board Certified Behavior Analyst. In 1990, she founded The Center for Autism and Related Disorders, and through its fourteen offices she has helped thousands of children affected by autism, Asperger's syndrome, and PDD-NOS. CARD services include assessments, supervision, parent/teacher training, and one-on-one behavioral therapy. Through Dr. Granpeesheh's vision of helping as many individuals with autism as possible, CARD has become an industry leader in administering effective multi-disciplinary treatment plans.

Presentation:

I'm very excited to be a part of Thoughtful House, where we're bringing Applied Behavioral Analysis (ABA) therapy and biomedical treatments together; we intend to develop the best-practice treatment for autism. My presentation is very different from the others you've heard today. I'm a PhD. I'm a clinical psychologist. I'm a behavioral analyst. What I'm going to present to you today is a behavioral-educational program for kids, which will work together with biomedical treatments. I'm going to talk about this full-treatment approach, and I'll present a brief introduction to ABA. I'll explain the CARD program, and then show you a curriculum for teaching kids with autism.

What do we know so far about autism? We know that there's a genetic predisposition. We know about the gastrointestinal issues and the immune dysfunction, and that environmental insults serve as a contributing factor. So, we know that there is a biological basis for the disorder. But the diagnosis of autism is based on behavior, on language delay, social delay, and maladaptive behavior-these are the behavioral manifestations of a biomedical disorder. So, doesn't it make sense to do biological treatments as well as ABA? Biological treatment, of course, involves the elimination of all of the triggers, stabilizing the child's health, and thereby ensuring that the child's maximum learning potential is met. ABA increases skills and decreases maladaptive behavior, and then generalizes all those skills for daily living. These two things work very well together. Obviously, a healthy child eats better. If he eats better, he sleeps better and feels better, and then he can learn better, so it isn't surprising that in the twenty-six years I've worked in this field I've seen the greatest improvements in the children who have a program that includes both biomedical treatment and appropriate education.

Part of what we're going to be doing at Thoughtful House, in addition to the ABA therapy, is collecting a lot of data. We have the privilege of working with kids daily, so we get a lot of data on how the kids are improving through treatment. This is some of the data that we've collected over the last year or so (points to slide), just to show you how well ABA and biomedical therapies work together. This is a child that we saw in December of last year. When this child started treatment, as you can see on this chart, there was a lot of rage, noncompliance, and visual self-stimulatory behavior. You see these decreasing just through ABA treatment. Then the physician for this child adds Lexapro. You will notice the self-stimulatory behavior gets worse. But what happens next is that they add essential fatty acids (fish oils), and the behavior starts to improve. Now let me show you another slide of the same child, charting skills. These are language skills, social skills, and so on. You can see a huge change between September and October, which is when the fish oils were added. There was a huge improvement in this child. In September she was learning about 15 to 20 new concepts, and in October she learned around 70 new concepts. That kind of data is what we're looking forward to replicating.

I'm going to go back and define ABA. ABA is based on the principles of operant conditioning theory, which says human behavior is affected by events that precede it, which are called antecedents, and events that follow it, which are called consequences, so all you really have to do is change those events and you can change behavior. You can change what happens before a behavior, and what happens after a behavior, and it will affect the behavior itself. When treating an ASD child, we are trying to bring about change not only from a behavioral standpoint, but also from a diagnostic one. Right now, the diagnosis of autism is based on symptoms. The series of deficits in the diagnosis of autism are language, play skills, social skills, theory of mind, and executive function (which I will define later). There are also some behaviors that are excessive, like self-stimulatory behaviors, maladaptive behaviors, tantrums, aggression, noncompliance, and so on. The goal in ABA is to improve those areas that are deficient and to reduce those areas that are excessive. These are called "skill repertoire instruction" and "behavior management"; these two things work together. To give you some examples of behavioral management, let's say a child learns to tantrum to get what he wants, because he has no other tools for communicating. If we can teach him another way to ask for the objects or things that he wants, those tantrums tend to recede; but let's say the child screams when he doesn't want to do something, because he doesn't know how to say, "Mom, I don't really feel like doing this right now," so let's teach him to ask for a break. Or when the child hits to get your attention, teach him to call your name instead. There are a lot of different techniques that we use to try to replace those behaviors that have developed over time as a communication mode. The basic idea is that the kids are not behaving badly because they're bad kids. They're wonderful kids. They're behaving badly because they're trying to communicate something, and they don't have any other way to communicate it, and that's how their frustration is coming out.

Our treatment model is the ABA Foundation. We work with kids who range in age from 12 months to twenty-one years. It's intensive--we do about 30 to 40 hours of intervention per week with the children, because there's so much to teach them. It's a gradual shift from a home-based program to a school-based program, and, of course, we support the biomedical interventions and the physicians. This is what the shift from a home- to a school-based program looks like over a four-year period. In the beginning most of the therapy takes place at home. Over time, more and more of the therapy takes place at school until the child is completely mainstreamed.

At CARD we teach language, play, theory of mind, social skills, executive function, self-help/motor skills, and school skills. I'm going to go through them one by one. Let's talk about language first, which is, of course, one of the most important areas to work on. The way to look at language is that acquiring language is more than just learning the meanings of certain words. We have to teach the basic functions of language so that the child learns how to use language to communicate. I'm going to explain what I mean by that by using a very simple concept, which is a program to teach colors. Let's say you want to teach the child the color blue. There are several different ways in language that we use one concept, such as the color blue. For instance, when a baby is young and the mother is trying to teach the baby something, she might say "blue" and want the child to imitate it, so imitation is one function that we expect our kids to know. When the child is one or two, and wants the pink or blue lollipop and wants to request it, requesting is a different function of the same concept, blue. Let's say the child is in school now and the teacher says, "Match all the cards that are blue, or all the blocks that are blue,"--matching is a different way we want the child to understand the concept blue. Then, let's say there are crayons on the table and mom says, "Give me the blue one," that's receptive, and receptive is another way that we want the child to use that concept. Labeling (tacting)--they'll point and say "blue," so they're labeling an object, and that's a whole different function. Then, finally, there's conversation. What's your favorite color? What's the color of the sky? That's interverbal and that's a different function. If we teach only the label blue, there's no guarantee that the child is going to use that concept in all these ways, so it's very important to teach all these different ways for every concept, so that the child generalizes and uses what they're learning in daily life.

This is a clip of a child who is just starting out with us. He's doing a program that's mixed--Mand-Tact-Echoic-Intraverbal (stands for "request-label-repeat-converse") so he's doing four different types of things just in this one exercise. It's also important to keep in mind that while you're teaching those functions that I talked about--the sound, the language, the structure--you want to know whether or not he is getting the meaning across that he wants to. Syntax is the arrangement of language. It's different in every language. And finally pragmatics--social language, which is the hardest area to teach and a very long portion of our program. Our overall goal is to emphasize spontaneity, so the child learns to feel comfortable, and learns to use the language in daily life. Of course, there also has to be an emphasis on generalizing, because you want the child to be able to use language in different settings.

One of our most interesting curriculum books is on our play programs. What we've done is to develop a comprehensive play skills program, which is modeled on the development of play skills in normally-developing kids. We've placed each type of play into its own program; it's sequential, so you can teach the programs one by one, and you can also mix them up together. It follows normal development, so beginning play is the first area we work on. This is sensory-motor stuff, which means you are working with young children, so we always like to teach cause and effect. For instance, if you press a button, something lights up, or if you pull a toy, it makes a sound. That's the first type of play that needs to be taught. The second area is functional pretend play, which is usually developing around age two, and that includes things like picking up a toy telephone and pretending to talk. Then we go on to symbolic play, where now the child isn't using the toy telephone anymore but some other object--like a pen--and pretending it's a telephone. Then we work on constructive play, which is a whole series of games having to do with teaching construction, building with Legos, or crafts--anything that produces a product. That's the type of thing that you start to do around age three or so. And then we go to imaginary play, which is more appropriate for four year olds. Now they're not using a toy telephone or a block or something; they're pretending, and that's a very hard concept because they have to maintain visual things in their mind, in their memory, and pretend that they have a phone when one doesn't exist. That's an area that we focus on very extensively. Then there is socio-dramatic play, which means dressing up and pretending to be a fireman, or a mommy or daddy. Practice play is usually outside play. It consists of chasing and climbing and those types of activities. Then we teach games with rules, which are things like card games or board games. Throughout all parts of the program we're also teaching play tracking. We're trying to teach our kids to track the amount of play they have on different activities. It's important that they're paying attention to what their partners or peers want to play as well, and that they not become too obsessed about one type of play. The other thing that's interesting is that with every section of play that we teach, we make sure that it generalizes to a peer, so that the child is using that concept with another child. We do a lot of play dates.

The area of self-help skills is very important. Parents are always happy that we start out doing a potty-training program as the very first thing. We also start with an extensive feeding program for very young children, and progress on to all of the skills that they need in order to become functional. And then we look at motor skills--we work on everything from finger strength all the way to writing in cursive, and of course gross motor skills. Some of our kids actually are not walking or standing yet when they come to us, so we work on those skills, all the way to rolling, throwing, catching balls, and so on, which, of course, is very important both physically and mentally. Among other things, it helps the child integrate better at school. Toward this end we also teach school skills once the child becomes school-age. Usually our kids are being integrated into school around age three, four, or five, depending on their skills. Right after they develop enough language and executive abilities to understand what's going on at school, we start teaching math concepts and reading concepts.

The next area of instruction is called theory of mind. Theory of mind is the ability to understand that different people have different emotions, thoughts, knowledge, desires, beliefs, and intentions. A British researcher named Simon Baron-Cohen came up with the idea that there is a theory of mind deficit in autism. He did an experiment which he called the "Sally-Ann" or "false belief" task. This was several years ago. He had three groups of kids watching a cartoon: autistic kids, kids with Down's syndrome, and normally-developing kids, all around the age of five. There were two girls in the cartoon, Sally and Ann, and there were two containers and a ball in the room. Sally placed the ball in one container, and then she left the room. While Sally was out of the room, Ann moved her object to the other container. When Sally came back, the kids who were watching were asked: "Where will Sally look for the ball? Where does she think it is?" The normally-developing kids and the kids with Down syndrome all responded that she was going to look where she put it, in the box, because she wasn't there when Ann moved it. The kids with autism all responded that it was going to be in the basket, in the new location. They assumed that Sally knew what they knew. This has been replicated many times since then, so we're pretty certain that the kids have a very difficult time understanding that everybody else doesn't automatically know what they're thinking inside their own heads. If you think about this as parents, it probably makes a lot of sense, because if you ask your child what they did in school they usually get frustrated. Why should they have to tell you? You're supposed to already know. It's all due to the theory of mind deficit.

We wanted to understand this a little bit better, so we broke it down and asked, what are the skills you need in order to have a good theory of mind? And we saw that this actually develops very early in life. The very first few months of life, the infant starts to develop a sense of self. By nine months, they're already showing what's called joint attention, or social reference. This is when a baby looks at its mother and then looks to see where she is looking. They already know that their mother is looking at something else, and they want to see it too. That's the first sign of theory of mind development. At 16 months, pretend starts; that's when we start doing pretend activities with our kids. At 18 months, desire and intention. There was a study in which 18-month-old babies were watching adults try to take a toy apart and the adults didn't succeed. The toy was then given to the babies, and they started to do the same thing. In other words, they understood just by watching an adult that the intention was to take the toy apart. At two years, we start to understand that people have different emotions. At three years, children start to understand that other people know or think different things. At four years, they understand the whole idea of belief and false belief. This is the age when kids are beginning to say, "My mom thinks my brother is in bed sleeping but he's actually jumping on the bed." This is also the age when kids start to lie because they understand that they can. And five years is when we start to understand intentions. This is a big problem for our kids because they'll go to school and somebody will accidentally knock over their backpack or something and they get very upset and come home crying. They don't understand that it wasn't intentional. The concept of intentionality doesn't exist. So all of these areas have to be taught.

We start with teaching the children that different people have different desires. Then we teach sensory perspectives. For instance, my visual perspective right now is seeing all of you, and your visual perspective is seeing me. These are completely different visual perspectives, and that influences what we know. We teach that different people have different preferences. So if a child's grandmother comes to visit and brings everyone presents, she'll probably bring each person something different because we all have different preferences. And we teach that we all think different things and we believe different things and therefore our intentions are different. Then there's the huge area of deception--not just lying, but also playing tricks, and jokes. With an ASD it's incredibly difficult to understand deception.

Social skills is an entirely different curriculum. We have a collection of programs, procedures, and activities that we put together for teaching social norms and behaviors. These are designed to be used in all social environments--at home and in the community with parents, but also in school and on play dates with peers. There's a series of procedures; teaching social playing and following rules in different settings, community social behavior and how you behave in the park, at school, at home. And then there are specific skills. When we're teaching the specific skills we first start teaching things like singing in a group. This is one of the first ways to teach cooperation, and then we go on to things like sharing and turn-taking. The child might be three or four while we're working on those concepts. Then we teach cooperating, apologizing and negotiating, which, of course, also require theory of mind because the child now must have the ability to keep in mind how the other person feels during the sharing or turn-taking or apologizing or cooperating. Levels of friendship is a program wherein we teach the children to discriminate between how they behave with their teacher or a peer or a family member. Then, at the very most advanced level of this program, we teach the whole concept of winning, losing, and dealing with conflict, which is very, very difficult for our kids to understand.

That brings us to our series of programs for positive self-statements. One of the things I have seen over the years with my kids is that when they get to this level of programming, they're functioning and they're in school and they're starting to see differences between themselves and their peers. It's very important at that time to give them a lot of positive self-statements and build up their strengths, because otherwise they will start feeling very isolated and then they will start being very conscious of their weaknesses and differences. The boy that you saw on the video who was telling the joke is a fantastic piano player and also a guitar player. He's a good musician and that's why he's still very popular at school. Last month his mom called me and told me that he was just nominated "most likely to achieve" in his class.

Safety awareness is a big area, and also responding to social cues. Responding to social cues is something that we work on throughout the program. We're teaching the child to read the environmental cues, like facial expression. Because our kids don't understand other people's facial expressions easily, they might, for instance, force their own preference upon someone or walk up and stand very, very close to someone. They won't react automatically to how that person is reacting, so we need to teach them through this program.

Executive function is the last area I'm going to discuss. These are the functions controlled by the cortex of the brain, so a lot of this research comes from studying people who were in car accidents and lost functioning in that area. Now it's being applied to autism because we see very similar deficits. The executive functions are the processes that underlie goal-directed behavior, which involves the things you have to do to reach your goal. First you have to visualize the situation, then you have to identify your desired objective. And you have to determine a plan to reach that objective. Then you have to monitor your own progress towards the goal, and then you have to inhibit all the distractions so that you can actually get to that goal. What do we have to teach to get to that point? First of all we have to teach them how to deal with distractions so that they can stay focused. It's really basic. A child sitting in a classroom will have a very hard time inhibiting what's going on outside if they're sitting right next to the window.

We have several programs on flexibility in the school's curriculum. Kids develop a lot of routines, a lot of rituals, and they feel things have to be a certain way, and that holds them back; that's the obsessive-compulsive side of autism. We have different methods for teaching them flexibility. For instance, we'll play a game and we'll change the rules of the game and in learning to adapt the child becomes more flexible.

Working memory is the ability to keep information you learned before as it merges with new information, so that you can now take the new information and apply it to what you knew before. Some of the kids are extremely strong on things like visual memory, but they lose certain things that they learned before as they learn new skills.

Of course, the goal of the entire program is to improve attention. We have to focus on certain areas of attention. Dual attention is the ability to pay attention to your mother even though the TV is on, or to pay attention to your mother when she calls you and then go back to the TV, or to pay attention to the teacher when there's a lot of background noise. We work on those areas very specifically. Self-monitoring is an important area. We need to teach the child to observe his own behavior, give himself credit when it's good, and monitor himself when it's not so good. This takes a long time. This is an area we work on with six and seven year olds.

Planning and problem-solving are, of course, related. In our planning programs, we give the kids a difficult scenario and we have them try to solve that problem.

I've done my best in the given time to explain the ABA program and extensive curriculum offered at CARD, as well as the benefits of biomedical therapies. The Thoughtful House will be bringing together applied behavior analysis therapy and biomedical treatments as a "best practice" model for treatment for children with autism. Thank you very much.

Cynthia
(Cynthia Macluskie)

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