Adams Intervention Plan

Adams Intervention Plan Monique Janssen, Tracy Southworth, and Pat Veleno University of Calgary APSY 674 April 15, 2010

Adams Intervention Plan Adams Intervention Plan Evidence Based Interventions at School Functional Behavioural Assessment (FBA)

Treatments based on the results of functional analyses are at least twice as effective as other treatments for individuals with Autism and developmental disabilities (Alberta Learning, 2003; Carr et al., 1999), and are less intrusive than interventions developed using other methods (Freeman, 1993). A Functional Behavioural Assessment (FBA) is a process of gathering information that can be used to maximize the effectiveness and efficiency of behavioural supports (ONeil, Horner, Albin, Sprague, Storey & Newton, 1997). The intent of the FBA is to acquire information about the function of behaviour and the environmental conditions contributing to the occurrence of problematic behaviour. This includes antecedent conditions that trigger the occurrence of problematic behaviour, and reinforcing (consequent) conditions that increase the likelihood of behavioural recurrence. Acquiring this information can help inform effective, individualized treatment planning. Finally, functional assessment is widely considered a professional standard for psychologists, teachers, and adult service providers delivering behavioural support to children and adults with disabilities, and is therefore considered an expected practice (ONeil et al.). The purpose of the FBA is to help determine the functional, biomedical, and environmental conditions contributing to the occurrence of Adams problematic behaviours, including his tantrum behaviours (anger outbursts) and environmental aggression, i.e., throwing objects when angry. The FBA requires that behavioural assessment information be acquired via direct and indirect methods. This includes speaking directly with all mediators involved in Adams direct care, such as his parents and his teacher/school support staff, to help determine

Adams Intervention Plan patterns of behaviour and contributing variables or setting events. The information can be collected via the distribution of appropriate questionnaires or rating scales, such as the Durand Motivation Scale or Child Behaviour Checklist (CBCL). Direct observation is also required as part of the process of completing an FBA. This involves spending time systematically observing Adam in his natural settings ideally both at home and at school, whereby the passive observer attempts to gather information regarding the frequency, intensity, duration, and discrimination of the problematic behaviours. This is typically done by recording when the behaviour occurs, what was happening both prior and

subsequent to the occurrence of the behaviour, and attributing a function to the behaviour in that instance. Once enough data is collected in this regard, a pattern of behaviour will tend to emerge, whereby a hypothesis concerning the function of behaviour is generated which helps yield/guide important treatment information. The collection of behavioural (Antecedent Behaviour Consequence) data can also be collected with the help of mediators within both the home, i.e., parents, and classroom settings, i.e., teacher. Generally, the process of completing an FBA will take anywhere from one to two weeks. This will help establish baseline performance measures across the target behaviours of concern, and once intervention is introduced, allows for an effective means of comparison to determine program effectiveness. Typically, the FBA is completed by a psychologist, behaviour therapist/consultant, or by specialized school staff trained in behaviour management principles. Treatment integrity (is ensured by involving all significant caregivers in the information gathering process, using direct and indirect measures, including reviewing school records, medical reports (if available), report cards, etc., and gathering accurate and reliable behavioural data.

Adams Intervention Plan Applied Behaviour Analysis (ABA) According to Baer, Wolf, & Risley (1968), Applied Behaviour Analysis (ABA) is the

science in which procedures derived from the principles of behaviour are systematically applied to improve socially significant behaviour and to demonstrate empirically the procedures used were responsible for the improvement. ABA incorporates systematic measures of performance with specific data collection procedures; is objective and empirically based; and ensures that clinical decision-making is directly influenced by direct evaluation (Green, 1996). A large body of evidence provides empirical support for the use of ABA / positive behavioural supports as the first course of treatment for problem behaviour (Perry & Condillac, 2003). Similarly, the New York State Department of Health (1999) developed guidelines for intervention practices with autistic children and noted that ABA is an important element of any intervention. ABA takes a constructive approach that incorporates instructional methods such as positive reinforcement, shaping, task-analysis and chaining to promote skill acquisition, generalization and maintenance. Behavioural data is gathered regularly, and performance is evaluated objectively. This helps to inform program evaluation and influences clinical decisionmaking. With respect to Adams behavioural presentation, the application of a contingency-based program, such as a token economy, can be used to reinforce the occurrence of appropriate replacement behaviours that serve the same function as the problematic target behaviours, as determined by the FBA. In Adams case his love of domestic canines can be utilized as a means of reinforcement. In this case, Adam would be given a sticker or checkmark for engaging in effective problem-solving, i.e., using his words to ask for a break, walking away, asking an adult for help, etc.; and relaxation exercises, i.e., deep breathing, muscle-tension-release, and

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communicating appropriately, i.e., in a polite manner, using a conversational tone, etc. Given his high levels of interest in dogs, his motivation would theoretically be very high to have an opportunity to engage in an activity that would allow him to explore this subject area further, i.e., going to the library to do canine-related research, speaking to the class for a short duration about a breed of his choice, etc. In order to earn this reward; however, Adam would be required to engage in the aforementioned socially appropriate replacement behaviours. Each time that he is noted to engage in the behaviours targeted for acceleration, he would receive verbally specific social praise, i.e., Great job using your problem-solving skills, Adam, coupled with a token. Adam would be then required to earn a predetermined number of tokens per day or week which he would exchange for access his desired reinforcer, i.e., canine-related activity. This intervention can and should be applied both within the home and school settings, by his teacher and parents, respectively, to promote consistency and increase overall chances of success. The intervention would be implemented subsequent to the completion of the FBA, i.e., post two weeks, and would endure for a period lasting six weeks or more. Program effectiveness would be evaluated periodically throughout. For instance, it may be worthwhile to meet with all mediators involved in the implementation of the program after an initial two-week period to gather information, provide consultation and problem-solve. Subsequent follow-up meetings would be scheduled within the home and school settings, respectively, at the four and six week marks, to review behavioural data, ascertain progress, and modify the approach, as required. Treatment integrity is ensured by having all mediators attend a behaviour management workshop prior to program implementation, which would cover basic aspects of behaviour management and assessment principles, in conjunction with data collection procedures. Furthermore, the behaviour consultant will model appropriate program implementation within

Adams Intervention Plan the home and school setting for all mediators involved as a means of training, and will follow through with weekly or biweekly student observations and/or program fidelity checks. Social Skills Training (SST) Students with Aspergers Syndrome are often integrated into regular classrooms but experience problems with social skills that prevent them from establishing friendships (Mayer,

Van Acker, Lochman, & Gresham, 2009; Rao, Beidel, & Murray, 2008). Because these students usually have normal cognitive abilities, they are aware of these deficits and differences but do not know how to address them (Rao et al.). Social Skills Training (SST) describes a variety of programs that usually involve groups of children with Aspergers Syndrome meeting and practicing hypothetical or dramatized scenarios as they learn how to interact in different situations and navigate their social environment (Rao et al.; Wood, Drahota, Sze, Van Dyke et al., 2009). Empirical support for SST varies depending on the intervention program, sample size, outcome measure(s), heterogeneity of the sample, duration of the treatment, and where the services are provided (Rao et al.). Rao and colleagues concluded that successful SST programs are designed for homogeneous groups of students, occur in the environment in which the skills will be used, target specific skills, and incorporate direct practice of the skills. Barry, Klinger, Lee, Palardy, Gilmore, and Bodin (2003) tested a SST program that used social scripts on four children with Aspergers syndrome who were in elementary school. This program specifically targeted the social skills of greeting, conversation, and play through eight weeks of two hours a week sessions in which students were directly taught scripts and then practiced while interacting with trained typically developing peers. An example of a script that the students were taught is one used for introducing yourself to another person. This script has eight steps where the student needs to: (1) turn his body toward the person, (2) look at the

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persons eyes, (3) smile, (4) say Hello, Im Adam. Whats your name?, (5) wait for the person to say his or her name, and (6) say, Its nice to meet you. Scripts are specific to the social situation so a large number of scripts must be taught to cover the majority of social situations (Mayer et al., 2009). Barry and colleagues found that the participating students showed more greeting and peer initiation behaviors, but no changes were observed in their ability to carry on reciprocal conversations. The students also reported that they had increased feelings of social support from their classmates. Another SST treatment that has proven effective used role-play to teach appropriate use of sharing of ideas, compliments, offering help, recommending changes, and exercising selfcontrol (Webb, Miller, Pierce, Strawser, & Jones; 2004). This program was investigated with 10 boys aged 12-17 who were diagnosed with Aspergers syndrome over a period of six and a half weeks. Before the boys began the intervention their parents attended an education session and their teachers received two training sessions. During the intervention the group met for 60 minutes at a time, twice weekly and used role-play and games to practice the targeted social skills. Following the treatment, the 10 boys had increased their ability to correctly identify the appropriate social skill for the situation, share ideas, give compliments, offer help, and recommend changes. However, parent and teacher ratings suggested that this knowledge did not generalize to the school and home environments. SST is an appropriate treatment for Adam given his ongoing difficulties associated with initiating and sustaining social interactions, entering group play with other students, conversing about unfamiliar topics, and making appropriate comments (Mayer et al., 2009). These deficits need to be addressed so that Adam can enter the classroom without monopolizing the teachers time, interact appropriately with other students at recess, enter conversations and games without

Adams Intervention Plan correcting his peers, and make appropriate comments about other students lunches. For these reasons, an eight-week SST intervention group will be implemented for Adam and other similarly aged students with Aspergers Syndrome or high functioning autism (HFA) within his school. This group will meet for 60 minutes a week, using social scripts and role-play to teach skills related to appropriate interaction with typical peers, and playground practice. The social scripts that Adam is taught will be individualized to meet his needs, with a specific focus on appropriately limiting how long he can talk about canines, how to initiate a conversation with peers, and giving compliments rather than insults. Adam will role-play situations in which he practices these social scripts with the other members of the group and then will practice these skills with typically developing peers. Finally, sessions will incorporate supervised direct practice with these same peers and others during recess.

The psychologist running this SST program will also teach the students in the group how to play popular games most commonly played by other students during recess. These games often involve a social interaction component, making it difficult for students with Aspergers Syndrome to learn the rules; so direct instruction makes their participation easier (Mayer et al., 2009). The psychologist who delivers this treatment will be experienced in treating students with Aspergers Syndrome and delivering SST. One typically developing peer will be paired with each student with Aspergers Syndrome to act as his or her recess buddy. These typically developing peers will be carefully selected for their ability to model and patiently work with students with social skills deficits. They will be encouraged to help their peer with Aspergers Syndrome in using appropriate social skills during group work and recess (Mayer et al.). Finally, the teachers will receive a training seminar on reinforcing appropriate social skills and supporting the students with Aspergers syndrome with entering play in the yard.

Adams Intervention Plan The effectiveness of the intervention will be assessed with teacher and parent

questionnaires of Adams social skills pre and post treatment. Additionally, Adam will complete a questionnaire rating his perceptions of his social competencies following the intervention. The intervention will be deemed effective based on teacher, parents, and student (Adam) ratings of social competencies following treatment. Reviewing the psychologists session notes to determine whether the social skills of concern were the ones targeted by the social scripts will ensure treatment integrity. Additionally, teachers will be provided with a checklist of steps to take when encouraging or reinforcing social skills and the psychologist will observe the classroom teacher at least once to ensure that the steps are being followed. Cognitive Behavior Therapy (CBT) The use of Cognitive Behavior Therapy (CBT) with people diagnosed with Aspergers Syndrome makes intuitive sense, as these people commonly have secondary impairments that have been successfully treated with CBT (Mayer et al., 2009). Thus far there is limited empirical evidence supporting the use of CBT with children with Aspergers Syndrome, although CBT interventions are growing in popularity as more rigorous research is conducted on its effectiveness for people with Aspergers Syndrome and social skills impairments, anxiety, or depressive disorders (Mayer et al.). Based on available research findings, CBT that focuses on identifying emotions, using fear hierarchies and gradual exposure, identifying irrational thoughts, and using coping statements has been found the most effective (Mayer et al., 2009). Wood, Drahota, Sze, Har, Chiu, and Langer (2000) found that children with Aspergers syndrome and an anxiety disorder who received individual and family CBT outperformed a waitlist group on diagnostic outcomes and parent reports of childhood anxiety. These gains remained at a three-month follow up (Wood, Drahota, Sze, Van Dyke et al., 2009). In this case

Adams Intervention Plan 10 the Building Confidence manualized treatment for anxious children was adapted for children who also had Aspergers syndrome so that a modified manualized treatment was created (Wood, Drahota, Sze, Chiu, et al.). The CBT treatment needed to be modified to address common problems for children with Aspergers Syndrome including stereotyped interests, adaptive skills, and social problems in order to be effective (Mayer et al., 2009; Wood et al.). CBT is appropriate for Adam given his frequent hand washing/sanitizing and need for rigid and predictable schedules are significantly interfering with his life. A registered school or clinical psychologist will provide Adam and his family with eight weeks of weekly 90-minute treatment sessions in order to help relieve the anxiety symptoms. Within these sessions, Adam will meet with the therapist individually for 30 minutes and then the family will meet with the therapist for the remaining 60 minutes. The 90-minute sessions will follow the manualized treatment developed and tested by Wood, Drahota, Sze, Chiu and colleagues (2000). This treatment is broken down into modules and the therapist individualizes the treatment on a session-by-session basis by choosing the module that addresses the most pressing clinical need (Wood, Drahota, Sze, Har et al., 2009). A priority for Adams treatment will be the use of a fear hierarchy, systematic desensitization and in vivo exposures to address his irrational fear of germs and promote habituation. Other focuses of Adams treatment will likely include coping skills training including affect recognition and cognitive restructuring; in vivo exposure to feared situations and teaching coping skills; adaptive skills; and behavior management. The parenttraining component will focus on teaching the parents to positively reinforce Adams practice, encourage Adams independence and autonomy in daily routines with communication, and practice facing feared situations with in vivo exposures (Wood, Drahota, Sze, Har, et al.). Adam will also be encouraged to take responsibility for managing his daily schedule through diary

Adams Intervention Plan 11 keeping to reduce anxiety. However, Adams teachers and parents will have to be vigilant with respect to reminding him to record routine changes (Mayer et al., 2009). Wood, Drahota, Sze, Har and colleagues (2009) incorporated social skills training modules into this treatment but these modules will be foregone since Adam will already be receiving this treatment though the SST group. While Adams social skills will not be directly addressed using CBT, they will play a large role in how the treatment is delivered. Adams social impairments may negatively impact his ability to work collaboratively with his therapist, resulting in barriers to treatment success, so a more directive approach may be necessary (Anderson & Morris, 2006). Anderson and Morris advocate adding visual communication such as diaries and diagrams in conjunction to verbal communication to facilitate comprehension. Tape recorders and computers may also help Adam feel distanced enough from potentially uncomfortable personal interactions to aid his communication with the therapist. Additionally, cognitive impairments that are common in people with Aspergers syndrome lead to difficulty with generalizing learning from therapy sessions into daily life, so a greater emphasis should be placed on practicing skills in the settings in which they will be used, and training teachers and family members to support the practice of these skills (Anderson & Morris). The CBT treatment will be considered effective if Adams parents and teacher report a decrease in the frequency and duration of compulsive hand washing and an increased tolerance for changes in daily routines. A self-assessment by Adam will not be used as Wood, Drahota, Sze, Har and colleagues (2000) did not find children with Aspergers syndrome to be reliable reporters of their own feelings. Treatment integrity will be assessed by audio taping therapy sessions and rating adherence to program plans. Wood, Drahota, Sze, Van Dyke and colleagues (2009) developed a checklist for each module of the CBT treatment so a trained rater will assess

Adams Intervention Plan 12 the treating psychologists adherence to important elements of the module while offering treatment. Additionally, the psychologist will check in with the parents weekly to assess their adherence to alternate elements of the intervention, including use of positive reinforcement, communication, and exposure to fear protocols following the parent training. Classroom Strategies Teachers play a crucial role in supporting children with Aspergers Syndrome. Recommendations of evidence-based strategies teachers may implement are discussed as they relate to the problem areas addressed. These strategies are practical and respect the needs of all the children and adults working in the classroom. Focus and Attention Like many students with Aspergers Syndrome, Adam struggles to stay focused during an activity (Marks et al., 2003). Marks and colleagues suggest using strategies that center around visual reminders to stay on task; thus minimizing the need for verbal cues. For example, the teacher could walk by and touch Adam's paper to nonverbally prompt him to continue working (Marks et al.). Similarly, the teacher may use a stop hand signal to remind Adam to stop talking about dogs (Safran, 2002). It is important to note that these strategies do not draw attention to the individual but rather support him in an inconspicuous, private manner, thus preserving his dignity and limiting the possibility of negative social perceptions. Visual cues may also be used to help Adam keep track of his workload. For example, Adam may keep track of finished and unfinished work by using a white board to write down directions or instructions, and crossing off each task upon its completion (Marks et al., 2003). A workbasket may also be used as a visual reminder to indicate how much work is required. When the basket is empty his work is done (Marks et al.). Winters (2003) suggests using an egg timer

Adams Intervention Plan 13 or alternate visual timer to set the amount of time allotted for a task and point out what work needs to be completed before the time goes off. Changes in Routine Individuals with Aspergers Syndrome may experience difficulty in transitioning from one activity to the next (Marks et al., 2003). These individuals may become particularly stressed about not being able to fully complete an activity before moving on to the next activity (Marks et al.). To support these students, Marks and colleagues recommend providing visual and concrete structure to help ease transitions. For example, the teacher may use a calendar, write assignments on the board, or make "to do" lists to show Adam specific and concrete beginning and end points for activities that continue over several days or class periods (Marks et al.; Safran, 2002). Also, whenever possible, teachers should provide Adam with advanced warning of upcoming changes in routine, where possible, and explain changes in routine prior to their occurrence (Safran, 2002; Winter, 2003). Reminder notes and prompts to refer to visual aids may help decrease Adams tendency to repeat questions about the routine, schedules, and expectations (Safran). Positive Peer Relations Safran (2002) suggests that teachers help create an "official peer buddy system that emphasizes friendship, respect for difference, and social interaction" (p. 6). Individuals with Aspergers Syndrome do not internalize social rules, have difficulties with metaphorical comments and sarcasm, and misinterpret benign teasing (Safran). In these situations, teachers and designated peers may act as interpreters to help comfort the student with Aspergers Syndrome, label the experience (i.e., that was a joke), and understand the other person's point of view (Safran). Capitalize on Special Interests

Adams Intervention Plan 14 Safran (2002) cautions educators not to encourage the self-defeating, obsessive behavior of students with Aspergers Syndrome. Instead, mediators should use the student's special interest as a bridge to learn or tutor others in classroom-specific content (Safran; Winter, 2003). For example, Adam may channel his interest in dogs to helping other students write, explain or do a project focusing on the needs of animals. Winter suggests that teachers motivate their students with Aspergers Syndrome by showing them the relevancy of learning alternate skills being studied in class such as using the computer, research, and report writing, and pointing out how they can be applied to their special interest, i.e., by learning how to use the computer to do research on canines, etc. Olfactory Sensory Sensitivity It is not uncommon for a child with Aspergers Syndrome to be sensitive to smells (Winter, 2003). Gabriels and Hill (2007) recommend using direct therapeutic sensory intervention, which allows an occupational therapist to provide children like Adam with opportunities to experience sensory input at a moderately challenging level. The goal of direct therapeutic sensory intervention is to modify the sensory environment in order to help children cope with environmental challenges (Gabriels & Hill). Direct therapeutic sensory integration also allows the occupational therapist to explore sensory inputs that have a calming versus arousing effect on children with Aspergers Syndrome (Gabriels & Hill). As a result of direct sensory integration, sensory accommodations may be made through a sensory diet, which controls the level and type of sensory input, thus allowing children with Aspergers Syndrome to participate in daily activities. For instance, Adam may be encouraged to bring a small item infused with a calming smell to class, or the teacher may allow fresh air to circulate through the classroom (Winter).

Adams Intervention Plan 15 Occupational therapists may also help educators and Adam's family members to reframe Adam's sensory sensitivity, thereby encouraging problem solving to identify effective strategies to deal with the problem (Gabriels & Hill, 2007). Specifically, Gabriels and Hill suggest modifying the environment, task demands, and routines to optimize the fit between the child and sensations. For example, the teacher may make arrangements for Adam to go home at lunch or eat in the office if necessary. Sensory Stories provides children with a tool to independently cope with the unpleasant sensory input of a particular situation (Gabriels & Hill, 2007). Sensory Stories may encourage Adam to use calming sensory strategies to help manage sensory experiences encountered during lunch time (Gabriels & Hill). When reviewed regularly, Sensory Stories may support Adam in developing an effective routine to manage his olfactory sensitivity. Finally, with the help of a psychologist, systematic desensitization can be used to help gradually reduce Adams sensitivity to offending odors. Reducing Anxiety Children with Aspergers Syndrome may be supported in reducing their anxiety through the use of physical objects. Winter (2003) suggests that the repetitive motion of squeezing and squashing a stress ball or another fiddle toy may help calm and relieve tension. Students may also be taught that there are safe alternatives to hitting people such as crushing pop cans for recycling or tearing up cardboard boxes so that they can lay flat in a recycling bin (Winter). Children may be taught to manage their anxiety by talking through the physical and emotional cues that indicate escalation (Winter, 2003). In Adam's case, anxiety management strategies may help him to think before becoming upset and saying something to hurt someone's feelings. Specifically, when the children notice that they are getting angry, they learn to: stop

Adams Intervention Plan 16 what they are doing; think about their behavior options and what the consequences of those choices may be; choose the option that keeps them safe and respond accordingly (Winter); and, evaluate outcomes. Additionally, children may be encouraged to slowly count to 10 when they are getting angry, use deep breathing exercises, or muscle relaxation techniques (Mayer et al., 2009; Winter). Also, a bean bag chair or a designated spot such as the reading corner may provide a safe and calming place to go to if stressed or in need of quiet time (Winter). Many children with Aspergers Syndrome may repeatedly ask questions when becoming anxious or upset. Winter (2003) advises teachers to provide reassurance, provide an initial response, and divert or redirect the child's attention away from the anxiety-provoking situation by assigning the child to perform a favored or calming activity upon repeated questioning. Alternately, Adam may be taught to write the questions down in a notebook that can be shared with the teacher each day at a set time (Winter). Consequences and Rewards ABA involves the use of reinforcements to teach children like Adam to display socially appropriate behaviors and decrease problematic behaviors (Alberta Learning, 2003). It is important for educators to remember that inappropriate behaviors must be followed by a consequence that is relevant to what has happened and involves performing an action rather than just saying words (Winter, 2003). Winter explains that in order to decide upon a relevant consequence, educators should reflect on what precipitated the action. Adam's teachers may record the antecedent and observed consequences of his behavior on charts to aid in creating an environment that minimizes inappropriate decisions and provides information for effective program decision-making (Hall, 2009, as cited in Mastropieri & Scruggs, 2010). These are antecedent-based approaches intended to prevent the occurrence of inappropriate behaviour

Adams Intervention Plan 17 while encouraging the occurrence of socially appropriate replacement behaviours. An explanation of the consequence should be given with the help of visual aids or diagrams, once the child has calmed down (Winter). Winter (2003) states that reward systems may be an effective behavior management tool for children with Aspergers Syndrome as they have a keen sense of fairness and a strong need to achieve. It is also important to note that intrinsic rewards have much less effect on children with Aspergers Syndrome than they do on other children (Winter). When designing a reward program, it is important to note that a small reward given frequently often is more effective for children with Aspergers Syndrome, than a large reward given occasionally (Winter). This explains the utility and appropriateness of a token-economy for use with Adam. In-Home Strategies and Parent Support Parents are crucial in developing and implementing an intervention program that supports children with Aspergers Syndrome in their home and community environment. Furthermore, by including parental involvement in the development and implementation of the intervention program, this promotes cooperation and collaboration, encourages program adherence, and enhances consistency. Ultimately, this serves to benefit the childs learning. This program focuses on evidence-based strategies that strengthen the child's social and emotional relationships with family and friends. The program aims to be practical and suit the needs and lifestyle of the family. After-school Programs and Family Activities In order to foster development of Adam's social skills, Safran (2002) advises that parents put students with Aspergers Syndrome in well-structured activities or clubs that "might neutralize their social deficiencies" (p. 6). For example, Adam may meet people with similar

Adams Intervention Plan 18 interests through volunteering to be a dog walker, working at an animal shelter, or joining a kennel club. Carter and colleagues (2004) found that a club that was initially for children with Aspergers Syndrome and slowly integrated other children provided a safe and comfortable environment to learn how to make friends, play games, and participate in other social interaction activities that could be transferred to other places. Winter-Messiers and colleagues (2007) add that parents can help foster a positive relationship with their child with Aspergers Syndrome by incorporating their child's special interests into family and community activities. Participation in these activities will also help improve their child's communication, play skills, and strengthen leadership abilities (WinterMessiers et al.). Winter-Messiers and colleagues emphasize the importance of parents finding creative ways to incorporate these special interests into the family's daily routines. Sleep Adams parents should consider the use of massage therapy to help Adam fall asleep. Paavonen and colleagues (2008) found that sleep onset difficulties were more common amongst children with Aspergers Syndrome than children in a control group. In fact, Paavonen and colleagues reported that it took more than 30 minutes for 53.1% of children with Aspergers Syndrome to fall asleep compared to 10.9% of the children in the control group. Escalona, Field, Singer-Strunck, Cullen, and Hartshorn (2001) found that when parents were trained to administer massage therapy to their child with autism every night before bed, their children spent more time in a deep sleep and awoke fewer times during the night. Weishop, Mattews and Richdale (2001) found supporting evidence for a parent training extinction program to get children with Aspergers Syndrome to fall asleep alone and remain asleep in their own bedroom. This extinction program includes visual cues displaying a bedtime

Adams Intervention Plan 19 routine, the use of reinforcement procedures, and parent use of a doll to model the bedtime routine (Weishop et al.). Extinction techniques also entailed ignoring the childs crying or calling out behaviours during bedtime, and taking the child who came out of his room back without giving any attention (Weishop et al.). Anxiety/Compulsive Behaviors Children with Aspergers syndrome often demonstrate worry and compulsive characteristics associated with anxiety disorders such as Obsessive Compulsive Disorder (OCD) (Ghaziuddin, 2005). Reaven and Hepburn (2003) found support for the use of CBT techniques such as self-reflection and self-monitoring as well as language-based interventions such as social stories for the treatment of OCD symptoms in children with Aspergers Syndrome. An important modification to traditional CBT strategies such as cognitive restructuring is the presentation of a simple list of rules (Reaven & Hepburn). Ghaziuddin (2005) noted that a variety of treatment approaches used for individuals with OCD have been adapted for use in individuals with Pervasive Developmental Disorder (PDD). In particular, it is important to pay attention to environmental stressors that exacerbate obsessive and ritualistic behaviors (Ghaziuddin). Also, behavioral guidelines should be clarified to establish clear and consistent rules, gradual introduction of change, exploration of possible underlying factors and environmental precipitants, and using obsessive-compulsive behaviors to reinforce desirable behaviors (Ghaziuddin). Exposure and response prevention, which teaches individuals to confront OCD symptoms in a hierarchical manner, has also been found effective in individuals with Aspergers syndrome (Ghaziuddin; Raven & Hepburn, 2003). Psychotropic medications are integral to the treatment of obsessive-compulsive symptoms in individuals with Aspergers Syndrome (Ghaziuddin, 2005). These medications

Adams Intervention Plan 20 include selective serotonin reuptake inhibitors (SSRIs) such as sertraline, fluoxetine and clomipramine. Antipsychotic drugs such as Risperdal may also be used, although they are less often prescribed (Ghaziuddin). Routines Many individuals with Aspergers Syndrome and Autism Spectrum Disorder (ASD) prefer consistent routines and predictable schedules (Norton & Drew, 1994). Even a slight alternation in routine may prompt child with ASD to engage in outburst behaviours (Norton & Drew). In order to help children with ASD and their families deal with problem behaviors, researchers have found support for a parent implemented, Positive Behavior Support (PBS) intervention plan. This plan promotes the development of the child's abilities through teaching new skills and encouraging social engagement (Buschbacher & Fox, 2003; Dunlap & Fox, 1999). Additionally, the PBS program teaches prevention strategies focusing on antecedent manipulations through the use of stimulus control techniques and cues associated with desirable behavior, thus encouraging participation in activities and the use of acceptable behavior (Buschbacher & Fox; Dunlap & Fox). Replacement skills are also taught to help the child negotiate social contexts without using problem behavior (Buschbacher & Fox; Dunlap & Fox). Finally, the PBS intervention plan includes teaching the use of consequences, which provides ways for the parents to respond to the problem behavior so that the behavior is ineffective for the child (Buschbacher & Fox; Dunlap & Fox). Recommended Community Resources Community resources are available to families with children with ASD. One of the advantages to accessing community-based resources lies in the many options parents have at their disposal, especially in large urban centres, such as Toronto, and the related option to avoid

Adams Intervention Plan 21 waitlist requirements associated with publicly funded services. Fee-based services are typically associated with more immediate service access and are an option for those who are in need of urgent help or who have the financial wherewithal to afford the inherent costs. Psychologist/Behaviour Therapist In Adams case, his family would benefit from the services of a psychologist or behaviour therapist, who can complete a FBA, and develop, monitor, and evaluate an empirically-based, constructive treatment approach, using principles of Applied Behaviour Analysis, to address Adams behavioural deficits and excesses. This includes his tantrum behaviours, environmental aggression, social skills deficits, anxiety issues and sensory sensitivities. The psychologist or behaviour therapist would then provide caregiver training regarding behaviour management principles, and complete follow-up visits, as necessary, to help ensure program fidelity and problem-solve issues that arise within the home environment. Furthermore, Adams parents may also benefit from the services of an occupational therapist, which can help specifically address his sensory issues within the home setting. The Geneva Centre for Autism is a globally recognized centre for autism spectrum disorders. This centre offers multidisciplinary services, including psychological services, behavioural consultation, occupational therapy, speech and language consultation, and home/school consultation. It essentially has the capacity to act as a one-stop shop. Services are offered free of charge, though they are subject to a waitlist requirement. Alternately, parents have the option of purchasing services on a fee-for-service arrangement, which would then significantly reduce the wait for access to required behavioural services and occupational therapy services. The Geneva Centre also offers psychological services, behavioural services, in-home

Adams Intervention Plan 22 and in-school consulting services, mediator training, and occupational therapy services. The website for this centre is: www.autism.net Alternate service providers who can fulfill psychological and/or behavioural duties include: Pryor Linder & Associates - (905) 849-4545. This is a psychological private practice offering assessment, consultation, and programming services to a wide range of populations. Services are provided by psychologists or behaviour therapists, as requested, and are fee-based. Developmental Pediatrician Adams family requires the services of a qualified developmental pediatrician to help determine the need for pharmacotherapy to address Adams anxiety and sleep-related issues. A developmental pediatrician is uniquely qualified to deal with young children with special needs. Ongoing consultation would be necessary to ensure that Adam is benefiting from his medication regimen while monitoring for signs of side effects and/or improvement. One of the most highly regarded hospitals in Canada, and around the world, is the Hospital for Sick Children, based out of Toronto. This hospital caters specifically to the needs of children and has a number of wellrespected, highly trained medical specialists on staff, which commonly deals with developmental disabilities and other complex needs. This would certainly be a starting point to explore retaining the services of a developmental pediatrician. A referral would be necessary from a family doctor. The website address for this hospital is: www.sickkids.ca Respite Services Given Adam's high levels of anxiety, insistence on sameness, and intolerance for change, the family would probably welcome respite services in order to allow the caregivers the opportunity to 'recharge their batteries'. Caregivers cannot adequately support others if they are overwhelmed and stressed by the needs associated with their care. This may place a strain on

Adams Intervention Plan 23 interpersonal relationships and can affect physical, psychological and emotional well-being. Similarly, program fidelity and adherence suffers when caregiver stress is high. Given the many behavioural challenges associated with Adam's care, it is reasonable to assume that his parents would welcome intermittent relief to complete duties and chores associated with other aspects of their lives, or simply to relax. To that end, a number of service providers are available that can fulfill these duties. Bartimaeus Inc - offers fee-based services to families, agencies and schools supporting individuals with special needs (www.bartimaeus.com); Williams, Marijan & Associates (www.wmanda.com) - offers fee-based services specifically oriented to children and families with autism spectrum disorders. The Geneva Centre (www.autism.net) is a multidisciplinary centre specializing in autism spectrum disorders, offering a variety of publicly funded or fee-based services. Leisure and Recreational Given his social skill deficits and reduced areas of interest, Adam may benefit from having the opportunity to partake in novel, supported leisure and recreational activities, especially once he has learned to effectively manage his high levels of anxiety. He and his family may especially benefit from an extended opportunity to be with other children in an integrated environment, where experienced support staff can help successfully engage him and foster learning and enjoyment. Reach for the Rainbow (www.reachfortherainbow.ca) is a nonprofit organization that has pioneered the integration of children and youth with physical and developmental disabilities into the mainstream of society through integrated summer camp programs throughout Ontario. Subsidies are offered to families in need, and children are provided one-to-one support at a reduced cost. Other considerations include: Variety Village

Adams Intervention Plan 24 (416) 699-7167, which offers fitness, swim, and recreational programs to children with physical and developmental disabilities in a safe and family-oriented environment. Follow-Up to the Intervention After a period of 2 to 4 weeks, Adam's learning team should gather to discuss the successes of the intervention plan and make alterations to areas in need of improvement. GerzelShort and Wilkins (2009) state that a Response to Intervention (RTI) approach can be used to determine whether an intervention is having a positive impact on the students' learning. Throughout this process, the learning team continuously gathers data using observational, anecdotal, and progress-monitoring tools to determine Adam's response to the intervention strategies used. Additionally, the intervention impact on the family and other students in Adam's school is assessed (Gerzel-Short & Wilkins). Data should also be collected regarding the fidelity and integrity of the implementation of the interventions as this information may help identify variables associated with successful implementation (Mayer et al., 2009). All relevant information should be shared with the learning team members at the meeting (Gerzel-Short & Wilkins, 2009). If Adam has additional needs, the learning team needs to use a problem-solving process to isolate the skills and strategies in need of development (Gerzel-Short & Wilkins). Likewise, the learning team may identify barriers inhibiting success for the school and family systems. In order to better understand how to support Adam at home and in the school, members of the learning team may need to consult other professionals or attend professional development workshops (Gerzel-Short & Wilkins). A revised intervention plan should be created, in writing that takes into account the newly acquired information and details intervention goals, strategies for implementation and assessment procedures. Decisions regarding how the intervention should continue to be

Adams Intervention Plan 25 monitored should be made before the meeting is adjourned, as well as a follow-up meeting may be scheduled for later in the year to ensure that Adam continues to make gains (http://www.dlsped.k12.nd.us/pdf_files/RTI/SBIT%20FollowUp%20Mtg%20forms.pdf). This process involving intervention evaluation, communication, and revision should continue until Adam no longer requires the support. Recommended School Wide Intervention Most of the school wide intervention models aim to influence the students behavior and academic performance by altering the school context using established procedures for problem solving and clearly articulated rules (Bradshaw, Koth, Thornton, & Lead, 2009). The implementation of the Positive Behavioral Interventions and Supports (PBIS) program would help foster a positive environment for all students and set up positive expectations for behavior, rather than dealing with problems after they have occurred (Horner et al., 2009). This program is built on behavioral, social learning, and organizational behavioral principles whereby primary, secondary, and tertiary interventions are offered (Bradshaw et al.; Horner et al.; Sugai, Horner, & Lewis, 2009). The primary portion of the PBIS program involves formal training of five to six school staff on the formation and functioning of a collaborative PBIS team in their school and how to implement the intervention in their schools (Bradshaw et al., 2009). These staff are also trained on individualizing PBIS to their schools needs to create expectations for positive student behavior, define and teach these behavioral expectations to all students, develop a school wide reward system for exemplifying the positive behaviors, and agree upon a system for responding to behavior problems (Bradshaw et al.). Schools are also trained on and encouraged to collect data for decision making on effectiveness of current intervention and future intervention

Adams Intervention Plan 26 planning (Horner et al., 2009). The professionals who are selected for in depth training are then required to train the rest of the schools staff (Horner et al). Fully adopting the PBIS program typically takes two to three years and the schools core professionals attend annual two-day booster training sessions each summer and have access to behavior support coaches in the school four times a year (Bradshaw et al.; Horner et al.). In this case the primary intervention program could focus on conversational skills as a primary goal and Adam, along with the rest of the students in the school, would receive direct instruction on conversation skills. The PBIS intervention can build on Adams fixation on rules by presenting positive behavior expectations as rules that Adam needs to follow. Additionally, the teasing behavior that Adam is currently experiencing when other students call him teacher could be targeted so that other students learn to treat Adam more diplomatically. While the primary intervention component of the PBIS intervention will likely be of some benefit to Adam, the secondary and tertiary aspects of the program are what make PBIS the preferred school wide intervention model in this case. Secondary and tertiary behavior supports are designed to help students who are at risk or demonstrating problem behaviors and who may benefit from additional instruction (Horner et al., 2009; Sugai et al., 2009). The tertiary tier of support utilizes FBA and family or community involvement to increase the desired positive behaviors (Horner et al.). Targeting conversational skills using these more supportive treatments may provide Adam with the skills and confidence he requires to conduct a reciprocal conversation with others. Ultimately, the PBIS intervention is recommended as a method of improving the behavior of all students in the school while the additional targeted supports for students who require more formal training should allow Adam to benefit from the program. Empirical evidence suggests that this program decreases office referrals and improves academic

Adams Intervention Plan 27 performance (Horner et al.) while maintaining high treatment fidelity over five years (Bradshaw et al., 2009).

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