Practical Interventions for

Children with High

Functioning Autism and
Asperger’s Syndrome
Lauren Kenworthy, Ph.D. and
Laura Anthony, Ph.D.
Wednesday, January 30th ,
2008
CASD Outreach Night
 Center for Autism Spectrum Disorders
Faculty and Staff

Lauren Kenworthy, Ph.D. Peter Daniolos, M.D

Director Medical Director
Pediatric Neuropsychologist Child and Adolescent Psychiatrist

Laura Anthony, Ph.D. Kathleen Atmore, Psy.D.

Clinical Child Psychologist Developmental Neuropsychologist

Cheryl Anselmo, M.A., CCC-SLP Angela Bollich, Ph.D., SLP

Speech and Language Pathologist Pediatric Neuropsychologist

Joette James, Ph.D. Christine Amerasinghe/Katea Selby

Pediatric Neuropsychologist Clinical Operations Representative

Katie Jankowski/Jenni Sokoloff BenYerys, PhD/Rafael Oliveras, PsyD

Research Assistant Post Doctoral Fellows
Autism does not have one cause or
cure…
The triad of impairments in autism can be
fractionated and should be studied separately
(Happe, Ronald & Plomin, 2006)
 Single explanations of autism have not been
successful at explaining social deficits and
rigid/repetitive behavior
 Autistic like behavioral traits in typical children (twin
study 7-9 year olds) show only modest to low
correlations (Ronald et al, 2006)
 Autism is a heterogeneous disorder
Solution to the riddle:
➔ Teach by doing

➔ Teach process (make

implicit explicit)

➔ Go step by step

➔ Provide hard copy

Teach by Doing: Harder Than You
Think
 Intervene in everyday activities
with everyday people in the
context of a real problem
 Explicitly decode reasons for

change
 Positive verbal labels
Teach by Doing: Harder Than You
Think
 Model behavior
 Begin from an “external support”

position, slowly encouraging

internalization of routines
 Teach until automatic
Teach by Doing: “With, Not For”

 Collaborate with child

 Give child opportunity to solve

problem
 Elaborate responses

 Reward effort

 Hold child responsible for outcome

 Make all interventions positive

 Goal-Plan-Do-Review
GOAL: WHAT DO I WANT TO ACCOMPLISH?

PLAN: HOW AM I GOING TO ACCOMPLISH MY GOAL?

MATERIALS/ EQUIPMENT STEPS/ASSIGNMENTS

1. 1.
2. 2.

PREDICTION: HOW WELL WILL I DO?

Self rating 1 2 3 4 5 6 7 8 9 10
Other Rating 1 2 3 4 5 6 7 8 9 10

DO
PROBLEMS SOLUTIONS
1. 1.
2. 2.
3. 3.
REVIEW: HOW DID I DO?
Self rating 1 2 3 4 5 6 7 8 9 10
Other Rating 1 2 3 4 5 6 7 8 9 10

WHAT WORKED? WHAT DIDN'T WORK

1. 1.
2. 2.
WHAT WILL I TRY NEXT TIME?
 Incentives for Change
 Motivation “Let’s work on your Harry
Potter stuff”
 Collaboration child and teacher or
parent work together
 Rewards individually identified based
on each child’s interests, child will help
develop the reward system
 Positive Behavior Supports (PBS)
including praise and concrete progress
tracking (graphs, etc; Horner et al,
2002)
 MUTUAL
MISUNDERSTANDING
“A failure to understand how a child’s typical
behaviors reflect this disability can result in
misperceptions such as viewing the child as
noncompliant, willfully stubborn, or unmotivated,
rather than confused, involved in repetitive
routines, or focusing on less relevant aspects of
the situation.” (Kunce & Mesibov, 1998)
Misunderstanding/Failure to
Help
 What exactly is the problem?
 What is causing the problem?
 Physical, Cognitive, Self Regulatory,
Emotional, Behavioral
 Vary conditions to test hypothesis
 Team collaboration
 On-going process
 Placement Decisions
 Minimum requirements
 Staff with ASD expertise and team approach
 Safe address
 Specialized pull-out: social/executive support
 Best Practice
 Social/Executive support integrated
 Small class size
 Consider
 Windows of Opportunity
 Overload Effects
 Overload
 Structure, structure, structure
 Preview transitions, post schedules, stick
to routines
 Limit the number of adults/peers who work
with child
 Give breaks from people
 Avoid, decode or at least predict large
group or unstructured events
 Assign specific jobs or tasks
 Misses “Big Picture”
 Safe Address
 Teach to strength: explicit short rules,
recipes, checklists and routines
 Predict decline in abilities as
size/structure of group increases
 Put new information in familiar context
 Inflexibility
 Use prediction, routine and
repetition to support behavior
 Make schedule clear and public
 Forewarn of any changes in
schedule
 Give 2 minute warnings of time to
change
 Make changes from one task to the
next, or one topic to the next, clear
and explicit
 Inflexibility
 Assess understanding of situation,
devise Social Story
 Flexibility training
 Script (“This is not part of the plan,
is there a new plan?”)
 LEARNet Problem-Solving
System and Resource Website
 Self-Regulation/Executive Function Issues
 Problem Solving
 Self-Monitoring and Self-Evaluating
 Flexibility Versus Rigidity In Thinking and Behavior
 Impulsiveness / Disinhibition
 Inconsistency in Performance
 Self-Regulation / Executive Function Routines After
TBI
 Transition Routines
 Initiation
 Cognitive Egocentrism / Theory of Mind
 LEARNet Problem-Solving
System

and
Advance Organizers
Resource Website
 Attention
 Organization
 Retrieval and Retrieval Problems
 Approaches to Teaching: Traditional Training vs. Apprenticeship
 Word Retrieval and Word Retrieval Problems
 Memory and Memory Problems
 Slow Information Processing
 Transfer of Training / Generalization
 Reading Comprehension
 Concrete vs. Abstract Thinking
 Written Composition
Authors: Mark Ylvisaker, Ph.D., Mary Hibbard, Ph.D., Timothy Feeney, Ph.D.
The Brain Injury Association of New York State (2006)
http://www.bianys.org/learnet
 Poor Self-monitoring
 Videos
 Review situations with safe address
 Metacognitive narrative
 Slow interactions down
 Build in explicit, routine checking
procedures
 Make predictions
 Just Do What I Say!
 Written rules, recipes, routines, checklists
 Tapes
 Hand held computers
 Notebooks
 Dry Erase boards
 Talk out loud (Winsler, 2006)
 Memorize it, make it automatic
 Just Sit There!
 Activity breaks
 Increase structure in environment to set
limits for inhibition problems
 Make behavior and work expectations clear
and explicit; review with student
 Post rules in view; point to them when child
breaks rule
 Teach response delay techniques (counting
to ten before acting)
 Positive behavior management plans
 Intervention Project
Collaboration with Ivymount
Improved flexibility
in the classroom
Cognitive
Instruction
Better adaptive behavior

P
mir
yra
uo
oct
em
Less missed instruction time

Increased
Guided
Practice
Flexibility Improved fluency and
flexibility on cognitive tests

Improved behavioral regulation and

metacognition at school and home
gna h Cr of sevi t nec nI

Improved social skills

Generalization
Training

Improved flexibility at home

 Early Intervention
 Teach pretend play and joint
attention skills (Kasari, Freeman and
Paparella, 2006)
 Imitate your child
 Speech and Language therapy
Parent-child Interaction
Therapy (Eyeberg,
Herschell)
 Child Directed
Interaction
 Positive play therapy
 Developmental
approach
 Parent Directed
Interaction
 Compliance training
 Behavioral approach
Applied Behavioral Analysis
(Lovaas, 1987)
 Intensive behavioral techniques (30-
40 hours per week)
 Targets basic language skills,
behavior and academics
 Research shows remarkable
improvement in 50% of children
 Most appropriate for early
intervention in HFA, Asperger’s
 ACTIVE Social Coaching
Deconstruct social situations (e.g., Solomon,
Goodlin-Jones, Anders, 2004)
 Process social situations out loud
 Name your own feelings, what other person
might be thinking, feeling
 Stop action while watching videos and ask:
 Why did he do that?
 What will she do next?
 What is she feeling?
 What will happen if _____? (Gena et al, 2005)
ACTIVE Social Coaching
 Deconstruct social situations
 Interpret facial expressions,
gestures and body language out
loud for your child
 I can tell you are angry

because_____
 I could tell she didn’t have

time to talk because _______

 When I look at you this way, it

means that _____

 ACTIVE Social Coaching
 Social mentors
 Good for older kids and teens
 Social activities around special interests
 Pragmatic language therapy
 Drama (Asperger, 1944)
 Social Stories, Comic Book Conversations,
social skills workbooks, etc
 i.e., write it down! (Theimann and Goldstein,
2004)
 Social Stories (Carol Gray)
Riding the School Bus
Valerie Lowing
Some children ride to school on a bus.
Usually the bus will pick me up in the morning and bring me to
school.
Some children like riding the bus. They think it is fun.
Usually the bus will pick me up from school at the end of the
day and bring me back home.
Sometimes I will not ride the bus. Mom or dad will tell me when
I will not ride the bus.

http://www.thegraycenter.org/
 ACTIVE Social Coaching
 Social coaching in groups (e.g., RDI,
McAfee)
 Discrete skills
 Eye contact, turn taking, listening
 Pragmatic skills
 Social scripts
 “Opportunistic” skill building

 Challenge tasks

(Gutstein, 2000; McAfee, 2002)

 Family Burden
 Psychoeducation
 Family navigators
 “Similar to myself”
support
 Respite care
 Encouraging
movement towards
advocacy and
empowerment
 Behavioral Intervention
Strategies
 Aversives
 “No,” Time Out
 Differential reinforcement
 Replacement
 Extinction
 Stop reinforcing (IGNORE)
 Antecedent (cause) manipulation
 Behavioral Intervention for
OCD and Phobias
 Obsessive/compulsive or phobic
symptoms can be treated by Exposure
and Response Prevention Therapy
 Create a fear hierarchy
 Client picks where to start
 Expose client to feared stimulus
 Prevent escape/avoidance/compulsion
 Wait for anxiety to reduce
 Behavioral Intervention for
OCD and Phobias
 Must be done in the context of a
trusting therapeutic relationship
 Must be led by the child, and under
child’s control
 May take longer for those with ASD
 Anxiety
 Relaxation training
 Guided imagery
 Special interests
 Meditation
 Adapted yoga
 Cognitive Behavioral Therapy to help
identify anxiety, accept it without being
overwhelmed, and use cognitive strategies
to reduce anxiety
 Compliance
 Reward when intrinsic motivation
doesn’t work
 Collaborate together on behavior plan
 Integrate behavior plan in home and at
school
 Rewards and praise work better than
loss of privileges or punishments
 Magic ratio of 1:5
 Attention Problems
 Environmental adaptations
 Deep pressure
 Attention training sessions (using
behavioral methods)
 Joint attention training in young
children
 Meltdowns
 Prevention (warnings, preparation,
practice)
 Wait for the storm to pass
 Do not “give in” once meltdown has
started
 Don’t talk
 Provide safety and reassurance
 It is not your fault, don’t take it personally
 Preparing Now for
Adulthood
 Almost no research on long term
outcomes
 All information is on current adults using
retrospective data
 Adults with AS seem to continue to
make progress in core symptoms
 Best indicator of prognosis may be peer
relationships
 Asperger’s in Adulthood
 Transition planning and training must
start in middle school (elementary
school if you consider daily living
skills)
 Work issues: interests vs. skills
 College
 Need for support
 On-line vs. mainstream
 Foundational Skills
 Personal hygiene and professional dress
 Time management skills
 Professional demeanor (eye contact,
handshaking skills, etiquette)
 Limit lectures and talk of special interest
 Increasing tolerance for boring tasks
 Taking instruction
 Summary
 Interventions need to be multi-
disciplinary
 ASDs are developmental

disorders, so expect changes in

skills and problems
 Swiss cheese syndrome
 Resources
 Autism Asperger’s: Solving the
Relationship Puzzle by Steven Gutstein,
PhD (Future Horizons)
 Navigating the Social World by Jeanette
McAfee, MD (Future Horizons)
 Executive Skills in Children and
Adolescents, Dawson and Guare (Guilford
Press)
 Cartoon Cut-Ups Teaching Figurative
Language and Humor, Jean Hamersky
(Thinking Publications)
 Resources
 College Internship Programs-Examples
 The Brevard Center, Melbourne, FL, 1-866-603-
1900
 The Berskhire Center, Lee, Massachusetts
(413) 243-2576
http://www.berkshirecenter.org

 Foothill College Transition to Work Program

Los Altos Hills, CA, (650) 949-7242
http://www.foothill.edu/al/ttw.html
 Resources
 Meyer, R.G. (2001). Asperger Syndrome
Workbook: An Employment Workbook for
Adults with Asperger Syndrome. London &
Philadelphia: Jessica Kingsley Publishers.
 Smith, M.D., Becher, R.G. & Juhrs, P.D.
(1995). A Guide to Successful Employment
for Individuals with Autism. Baltimore: Paul
H. Brookes Publishing Company.
 Resources
 Autism Society of America www.autism-
society.org
 Yale
info.med.yale.edu/chldstdy/autism/welcome.html
 TEACCH www.unc.edu/depts/teacch
 National Information Center for Children and
Youth with Disabilities www.nichcy.org
 Resources
 Future Horizons
www.FutureHorizons-autism.com
 National Academy Press (free

version of Educating Children with

Autism, 2001) www.nap.edu
 OASIS

http://aspergersyndrome.org/
 Resources
 Autism Speaks www.autismspeaks.org
 Organization for Autism Research
http://www.researchautism.org/
 www.NationalAutismAssociation.org
Direct grants to families
 www.take2camp.org
 www.dcchildrens.com (Click on Departments and
Programs)