AUTISM

MEDICAL ASPECTS
INTRODUCTION
SCREENING AND DIAGNOSIS
DIAGNOSTIC/SCREENING INSTRUMENTS
Diagnostic Tools
Screening Tools
Functional Assessments
MEDICAL INTERVENTION FOR INDIVIDUALS WITH ASD/PDD
Accidental Injury
Sleep
Feeding/Nutrition
Stereotypies
Seizures
Dental Care
Sensory Issues
Puberty
Psychiatric Disorders
Attention Deficit/Hyperactivity Symptoms
Anxiety
Obsessive/Compulsive and Severe Ritualistic Patterned Behavior
Self Injurious Behavior
Tics
Aggression
Mood Disorder
ADDITIONAL INTERVENTIONS
Medications
Alternative Therapies

ESSENTIAL COMPONENTS OF INSTRUCTION

CONSIDERATIONS
Definition of "Curriculum"
Learning Styles of Individuals with ASD/PDD
Issues of Assessment
Aspects of a Learning Environment
FOCUS OF INTERVENTION - ALL AGES
Attention
Imitation
Communication
Socialization
Cognition
Purposeful Play/Recreation/Leisure
Essential Life Skills
ADDITIONAL FOCUS AREAS - AGES 6 - 21
Transition (Reference Community Transition Section)
Sexuality
Behavior
ESSENTIAL COMPONENTS OF AN INSTRUCTIONAL PROGRAM
Earliest Intervention
Intensity
Predictability and Structure
Generalization of Skills
Functional Analysis of Behavior and Behavior Interventions
Communication
Assistive Technology
Sensory Motor Processing
Social Development
Integration with Typical Peers
Assessment of Progress
Transition
Sexuality
Life Long Support
INSTRUCTIONAL ACCOMMODATIONS AND MODIFICATIONS
A. Time
B. Size/Amount
C. Participation
D. Input
E. Output
F. Difficulty
G. Level of Support
H. Modified Curriculum

COMMUNITY TRANSITION

OVERVIEW
COMPONENTS TO ACHIEVE
PRACTICAL TIPS FOR TRANSITIONS TO WORK AFTER HIGH SCHOOL
PRACTICAL TIPS FOR TRANSITIONING TO POST SECONDARY EDUCATION AFTER HIGH SCHOOL

FAMILY INVOLVEMENT

EFFECTIVE COMMUNICATION
TEAM PROCESS
INFORMATION AND ADVOCACY

PROFESSIONAL AND COMMUNITY DEVELOPMENT

APPENDICES

I. LEAST RESTRICTIVE ENVIRONMENT (LRE)

II. INCLUSION

III. DEVELOPMENTALLY APPROPRIATE PRACTICE

IV. FUNCTIONAL BEHAVIORAL ASSESSMENT

V. TRENDS AND OUTCOMES IN THE EMPLOYMENT OF PERSONS WITH DISABILITIES AND IMPLICATIONS FOR SCHOOLS AND THE MEDICAL COMMUNITY

EMPLOYMENT & EARNINGS OF PEOPLE WITH DISABILITIES
TRENDS OF CONCERN
UNDER-REPRESENTATION
IMPLICATIONS

VI. CHOOSING TREATMENT OPTIONS

QUESTIONS FOR PARENTS/CAREGIVERS TO ASK REGARDING SPECIFIC TREATMENTS AND/OR PROGRAMS:
POINTS FOR PARENTS/CAREGIVERS TO PONDER WHEN CONSIDERING PARTICIPATION IN A NEW INTERVENTION AND/OR PROGRAM:

VII. OHIO’S SYSTEM OF SERVICES FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDER/PERVASIVE DEVELOPMENTAL DISORDER AGES BIRTH THROUGH FIVE AND THEIR FAMILIES

EARLY INTERVENTION - BIRTH THROUGH TWO
PRESCHOOL SPECIAL EDUCATION - THREE THROUGH FIVE

VIII. FREQUENTLY USED TERMINOLOGY

IX. REFERENCES AND RESOURCES

GENERAL
COMMUNICATION
SENSORY INTEGRATION
SOCIAL
BEHAVIOR
SEXUALITY
INSTRUCTION
Curriculums
Assistive Technology
COMMUNITY TRANSITION
INTERNET
Autism Organizations
Autism Research
Bookstores/Videos
Federal Agencies
Other Disabilities Organizations
Special Education
Special Education Law
State Agencies
Transition

USER GUIDE

PURPOSE and SOURCE

THESE GUIDELINES OFFER BASIC CONCEPTS in providing supports for individuals with Autism Spectrum Disorder/Pervasive Developmental Disorder (ASD/PDD). The information and recommended strategies and modifications were compiled by committees and agreed upon by the "Task Force to Develop Guidelines for Educating Individuals with ASD/PDD Ages Birth to 21."

The guidelines are intended to serve as a tool that can be used to help families, educators, medical professionals, care providers and other service providers make informed decisions about children and young adults with ASD/PDD. They can be viewed as a map to the development of independence for the individual with ASD/PDD at the highest level possible in all life areas. The Guidelines are not a required standard of practice for the education of these individuals in Ohio.

These guidelines are intended to provide recommendations based on current knowledge about "best practices" for the assessment of individual needs and the delivery of appropriate services and supports to children and young adults with autism spectrum disorder. They are intended to help individuals with the disorder move from one developmental level to another and gain momentum in the process. The guidelines have a primary focus on children ages infancy to adulthood, however this is acknowledged to be an ongoing process.

The guidelines were developed in response to the rapidly growing body of knowledge that is available regarding autism spectrum disorder. This information has expanded the opportunities available to families and professionals to improve the lives of individuals with the disorder.

Several decades ago, if a child was diagnosed with autism, there was little hope for leading anything close to a "normal" life. In fact, many parents were encouraged by professionals at the time to place their child with autism into institutional care to spare the family the stress and heartache of attempting to raise the child. However, recent research has demonstrated that by providing the child with autism appropriate services and supports at appropriate developmental levels, significant gains in most life areas can be achieved and the person with ASD/PDD can thrive. Also, due to a shift to the "spectrum' view of ASD/PDD, we now are better able to identify and assist those individuals who have less severe forms of the disorder. These individuals were most often left undiagnosed in the past and did not receive many appropriate services or supports even though we now know they could have benefited greatly from them. This increased rate of identification has moved the diagnostic category of SD/PDD from being considered a low incidence disorder to a relatively high incidence disorder. This shift requires changes in attitudes, policies, and the allocation of resources to address the needs of every person with ASD/PDD in a fair and appropriate manner.

HOW TO USE THIS DOCUMENT

DESCRIPTION

The sections in this document cover a variety of information on autism:

• Definition
• Medical Aspects
• Components of Learning
• Components of Instruction and Resources

Autism is defined differently in the fields of education and medicine. A description and educational and medical definitions are provided. Education includes: Learning, Curricula and Instruction. An appendix on resources is also included for further reference and research.

It is recommended that the user of this document not look at the sections in isolation. Given the complex nature of ASD/PDD, delivery of educational supports often requires consideration of many aspects of the person at once. Cross-referencing is provided to assist the reader in gaining a more comprehensive understanding of each of the topics. Having the reader familiar with all contents of this document is ideal.

This document should be a part of your regular planning and training process. It should be used in tandem with continuous in-service training for families, educators, medical professionals, care providers and other service providers.

Practitioners and families are encouraged to use the information provided in these guidelines recognizing that the services should always be tailored to the individual. Not all of the recommendations will apply in every circumstance. The decision to adopt a particular recommendation must be made relative to circumstances presented by an individual and his or her family.

RECOMMENDED PROCESS

• When using this document to address a particular need, identify in the Table of Contents the section that most closely relates to the topic. Read the entire section and any referenced sections.
• Work with the education team to develop a plan. When related issues arise in the planning process, review those topics and referenced sections.
• Periodically review the progress, implementation and plan. The guidelines include recommendations for assessment, and can be used to generate next steps.
• Refine the plan and its implementation on a regular basis, returning to the Guidelines for further information and recommendations.

What this Document is NOT

These guidelines are not a required standard of education for individuals with ASD/PDD in Ohio.

They are not intended to support any specific intervention, treatment program, methodology, or medication.

Introduction to Autism

WHAT IS AUTISM OR AUTISM SPECTRUM DISORDER?

AUTISM IS A NEUROBEHAVIORAL SYNDROME resulting from a dysfunction of the central nervous system that leads to disordered development. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), published by the American Psychiatric Association (1994, pp.70-71), the onset of symptoms in autism occurs within the first three years of life and includes three general categories of behavioral impairment common to all persons who have autism:

• Qualitative impairments in social interaction
• Qualitative impairments in communication
• Restricted, repetitive and stereotyped patterns of behavior, interest and activities

There are a number of other common findings in children with autism that are not part of the diagnostic criteria. These may include unusual responses to sensory stimulation, behavioral disturbances and significant strengths and weaknesses in cognitive characteristics.

In recent years, the conceptualization and criteria defining the condition called "autism" have evolved significantly. The definition of autism has broadened so that autism is now seen as a spectrum disorder. For these guidelines, the panel agreed to use the terminology of "Autism Spectrum Disorder" (ASD) and "Pervasive Developmental Disorder" (PDD) which would include the disorders commonly diagnosed as Autism, Asperger Disorder, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS). The majority of specialists believe that the boundaries along the continuum overlap to a large degree.

Autism may be more common than previously realized, particularly if the broader definition of autism as a spectrum disorder is used to determine the number of cases. Earlier studies suggested that the prevalence of autism is about three to four individuals in 10,000, but more recent studies have suggested higher rates for the general class of ASD/PDD, up to or greater than sixty in 10,000. The higher estimated rates reflect inclusion of the broader range of autism, including milder subtypes on the spectrum (PDD-NOS and Asperger Disorder). The apparent increase may also be a result of improved diagnosis, but a real increase in prevalence cannot be absolutely ruled out.

DEFINITION OF AUTISM

Educational Definition (IDEA) - Federal Regulation-34 CFR 300.7 (c)(1)

1. Autism means a developmental disability significantly affecting verbal and non-verbal communication and social interactions, generally evident before age three, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in routine, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has a serious emotional disturbance, as defined in paragraph (b) (9) of Federal Regulation 34 CFR 300.7
2. A child who manifests the characteristics of "autism" after age three could be diagnosed as having "autism" if the criteria in paragraph (I) of this section are satisfied.

Ohio Definition

Autism Society of America Definition

Autism is one of five disorders falling under the umbrella of Pervasive Developmental Disorders (PDD), a category of neurological disorders characterized by "severe and pervasive impairment in several areas of development," including social interaction and communications skills (DMS-IV-TR). The five disorders under PDD are:

• Autistic Disorder
• Asperger Disorder
• Childhood Disintegrative Disorder (CDD)
• Rett Disorder
• PDD-Not Otherwise Specified (PDD-NOS)

Each of these disorders has specific diagnostic criteria as outlined by the American Psychiatric Association (APA) in its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).

Medical Definition (from DSM/IV)

Autistic Spectrum/Pervasive Developmental Disorder

Categories and Diagnostic Criteria

Overview of Autism Spectrum Disorder
ASD/PDD is a group of conditions with common dysfunction in the domains of socialization and communication. These include Autistic Disorder, Asperger Disorder, Rett Syndrome, Childhood Disintegrative Disorder and Pervasive Developmental Disorder-Not Otherwise Specified.

Autistic Disorder is the classic form of ASD/PDD with a prevalence of about 11:10,000 and a male/female ratio of 3-4:1. Diagnosis is usually made between age eighteen months to three years, with some children showing features in the first year of life. Individuals with this diagnosis have dysfunction in three core components.

• Qualitative Impairment in Socialization
  Socialization abilities are most severely affected in the early preschool years with the child either socially unavailable or a social loner. Social skills improve over time, but still show variable dysfunction ranging from remaining a social loner to acquiring social skills that are stilted and pedantic.
• Qualitative Impairment in Communication
  Impairment in communication ranges from absence of an apparent desire to communicate to excessive speech with poor interactive conversation. All individuals have impairment in pragmatic abilities, such as poor eye contact, voice modulation, and use and understanding of gestures and other nonverbal body/facial expressions. They are literal in interpretation of others’ comments and actions and have difficulties with insight into others’ actions and perspectives. Echolalia is usually present in a transient or permanent manner. Play usually shows a deficit in imagination and symbolic features, although some children will develop a restricted pretend play.
• Restricted Interests and Repetitive, Stereotypic Behaviors
  All individuals with autism have restricted activities and interests that can range from repetitive motor actions such as opening and closing doors to finger flicking, spinning and lining objects to fascinations in mechanical and cognitive themes. Resistance to change in routine is commonly seen in the preschool years and may persist to adulthood.

Other members of the PDD category:

• Asperger Disorder has a less severe impairment in socialization with difficulties interpreting social cues and naive/peculiar behavior. Language, while normal in achievement of developmental milestones, has associated problems in abstraction, interpretation and pragmatics. Areas of fascination are usually cognitively based. By definition, individuals with Asperger Disorder have borderline to normal intelligence and most have problems with fine and/or gross motor function.
• Rett Syndrome occurs after an apparently normal early infancy with a stagnation and loss of developmental skills between ages five to thirty months. This is associated with a deceleration of head growth, loss of purposeful hand use and replacement with stereotypic hand movements such as hand wringing and mouthing, gradual appearance of gait unsteadiness, and severe impairment in expressive and receptive language and in cognitive abilities. This disorder is primarily limited to girls, who may transiently show impairment with socialization during its evolution. Most develop seizures. Rett Syndrome is caused by an abnormality in the MECP2 gene on the X chromosome.
• Childhood Disintegrative Disorder has behavioral features similar to autistic disorder with onset between ages two to ten years after an apparently normal early childhood. It is sometimes associated with specific medical disorders and has a worse prognosis for significant improvement.
• Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS) is applied to children who have some, but not all, of the features of autistic disorder (either quantitatively or qualitatively). All individuals have impairment in socialization with either impairment in communication or restricted activities/interests. This category is not as well defined as the others and may inadvertently be applied to children with socialization difficulties due to other conditions.

MEDICAL ASPECTS

Introduction

This section describes issues related to diagnosis and medical concerns for individuals with ASD/PDD. It includes guidelines for medical assessment and intervention in a wide range of medically related areas. Many of the areas involve daily living skills such as feeding, sleeping, and dental care. Others are psychosocial in nature, such as anxiety, tics, and mood disorder. This section is best used in conjunction with the rest of the document because medical interventions alone may not be sufficient to change behavior or to maximize learning. It is, however, important to address potential medical problems because they can limit all other areas of development.

Screening and Diagnosis

Screening of all toddlers for a possible diagnosis of ASD/PDD is recommended. Because there are few, if any, well-validated screening tools for ASD/PDD in the school-age population, those who are exhibiting a concerning combination of language, social and behavioral difficulties are candidates for a more detailed evaluation. At risk children include those with social-pragmatic language difficulties, circumscribed intense interests, and significant dysfunction in social interaction.

Medical Key Points:

• Early identification as part of well child care visits
• Implementation of testing for identifiable etiologies
• Monitoring for co-morbid conditions
• Knowledge of pharmacologic and complementary medicine options

Medical lab testing can be helpful in defining an underlying etiology for ASD/PDD, although an identifiable cause is present in only a small percentage of this population. Most children will have already been evaluated in the preschool years. For those who have not been diagnosed or have had no medical assessment, the following is recommended.

1. Chromosomal Analysis. Up to 5% of individuals with autistic spectrum disorders have an identifiable chromosomal abnormality. Therefore, all children should have high-resolution chromosomal analysis and DNA test for Fragile X syndrome.
2. Electroencephalography (EEG) is not a routine study in this population. This test is indicated in individuals who have a history of autistic regression (normal developmental progress with loss of functional language and/or social skills) and in those with the clinical suspicion for seizures. The EEG study should be done in the awake and sleep state, recording at least one complete sleep cycle. Because some medications used for sedation for sleep can transiently suppress epileptiform activity, sleep should be recorded with natural onset (such as naptime or overnight sleep) or with medication that does not affect epileptiform activity.
3. Hearing and Vision Screens in all children.
4. Other tests should be ordered as clinically indicated and not because of the diagnosis of ASD/PDD. Children with developmental/cognitive impairment and ASD/PDD may be candidates for testing for inborn errors of metabolism, including amino acid and organic acid assays. Other studies such as allergy testing, immune workup and heavy metal assays should be done only if there are clinical features of these types of disorders.
5. Lead levels should be considered for children with ASD/PDD and excessive mouthing behavior or Pica.
6. Evaluation of Gastrointestinal Dysfunction. Despite anecdotal reports, no causal relationship has been established between gastrointestinal dysfunction and ASD/PDD. Since individuals with ASD/PDD can have GI dysfunction of diverse etiology (such as gastroesophageal reflux, disaccharidase deficiency and excessive juice intake), the evaluation should be based on the clinical presentation and not necessarily on the diagnosis of ASD/PDD.
7. Brain MRI rarely shows any significant abnormality in individuals with ASD/PDD unless there is a co-existing condition. Therefore, MRI is recommended only for appropriate clinical indications such as microcephaly, macrocephaly, seizures or focal neurologic features.
8. Brain Neuroimaging for Childhood Disintegrative Disorder. Individuals with childhood disintegrative disorder should have an evaluation that includes brain neuroimaging, awake and sleep EEG, detailed metabolic testing and other tests as indicated by the history and clinical presentation.

Similar to the preschool age child, the diagnostic assessment of a school age child should occur through a multidisciplinary approach. In addition to the medical evaluation, school age children should undergo formal psychological assessment by a child psychologist experienced in evaluating children with ASD/PDD. As a component for this assessment, the use of well-recognized diagnostic tools is imperative because of the presence of subtler symptomatology in this age group. Evaluation is necessary by a speech/language pathologist with expertise in assessing children with ASD/PDD, even in a child with apparently normal speech, in part to examine social and pragmatic skills.

The school has a role in the diagnostic assessment of a school-age child for possible ASD/PDD. In addition to being a source of referral for diagnostic evaluation, school personnel can assist by providing accounts of behavioral observations and academic and psychological testing information. For some children, a school visit by a member of the diagnostic team may be valuable.

The family is an essential member of the diagnostic team. Family members contribute by providing the important historical information. They can optimize their role by becoming familiar with the features of ASD/PDD and helping the diagnostic team recognize the features that may or may not be present in their child.

Diagnostic/Screening Instruments

DIAGNOSTIC TOOLS

Childhood Autism Rating Scale - (CARS)
CARS is a well-validated tool for the diagnosis of ASD/PDD. Its fifteen items include fourteen specific domains plus one category of "impression of autism". It is based on a rating scale from 1 to 4 that is scored with information from parent report, available records, and observation of the child. Training videos are available. (Schopler, Reichler, DeVellis, & Daly, 1988; Schopler, Reichler, & Renner, 1986)

Autism Diagnostic Interview - Revised - (ADI-R)
The ADI-R is a standardized semi-structured investigator-based interview of individuals with ASD/PDD. It can be used for children with mental age of or above eighteen months. There is good supporting research to confirm its reliability and validity. It takes several hours to administer and score. Primarily, it is a tool for use in research studies. (Lord, Rutter & Le Couteur, 1994 in the Journal of Autism and Developmental Disorders)

Autism Diagnostic Observation Scale - (ADOS)
The ADOS is a structured observation schedule for the diagnosis of ASD/PDD. It focuses on qualitative features of socialization and communication and has an interactive component. Several versions are available, including one for children who are not yet using phrased speech (prelinguistic-ADOS). Since it is used in a highly structured environment, it may not reflect the most severe or obvious features of ASD/PDD. Therefore, observations in non-structured settings and parent interview may be necessary. (Lord et. al., 2000 in the Journal of Autism and Developmental Disorders)

Gilliam Autism Rating Scale - (GARS)
The GARS is based on the DSM-IV definitions of ASD/PDD and has four sub-tests (stereotyped behaviors, communication, social interactions and developmental disturbances). This rating scale has good reliability and validity when used for the identification and diagnosis of individuals at or above age three. This scale can be easily and quickly completed by individuals who best know the child. (Gilliam & Janes, (1995), AGS Publishing)

Asperger Syndrome Diagnostic Scale - (ASDS)
The ASDS is a quick, easy-to-use rating scale that can help determine whether a child has Asperger Disorder. Anyone who knows the child or youth well can complete this scale. Parents, teachers, siblings, paraeducators, speech and language pathologists, psychologists, psychiatrists, and other professionals can answer the 50 yes/no items in 10 to 15 minutes. Designed to identify Asperger Disorder in children ages five through eighteen, this instrument provides an AS Quotient that tells the likelihood that an individual has Asperger Disorder. (Myles, Beck, Simpson, (2001), Pro-Ed)

SCREENING TOOLS

Autism Behavior Checklist - (ABC)
The ABC is a 57-item checklist that can be used as a screening instrument. It is used to estimate the severity of autistic features in an individual and to follow these features over time. It is not as reliable as the CARS or ADI-R. (From Krug, Arick, and Almond (1978))

Autism Screening Instrument of Educational Planning
(SECOND EDITION, ASIEP-2)
The ASIEP-2 rates individuals at or above eighteen months of age in five areas (sensory, relating, body concept, language, and social self-help.) It is used for evaluations and monitoring of individuals with ASD/PDD features. (David A. Krug, Ph.D., Joel R. Arick, Ph.D., and Patricia J. Almond, Ph.D., (1993), Western Psychological Services)

Checklist for Autism in Toddlers - (CHAT)
The CHAT is a brief checklist to screen for ASD/PDD in children at or above the age of eighteen months. It has two components:

1. A short list of questions for the primary caregiver
2. Observations in an office setting of behavioral features of ASD/PDD

Two studies have validated its usefulness as a screening tool for children with full features of ASD/PDD and, to a lesser degree, for children with high-functioning autism or Asperger Disorder. (Checklist for Autism in Toddlers. Adapted from Baron-Cohen S, Gillberg C. Can autism be detected at eighteen months? The needle, the haystack, and the CHAT. Br J Psychiat 1992;161:839)

Modified Checklist for Autism in Toddlers - (M-CHAT)
The M-CHAT is an expanded American version of the original CHAT from the U.K. The M-CHAT has 23 questions using the original nine from the CHAT as its basis. Its goal is to improve the sensitivity of the CHAT and position it better for an American audience.

First Signs Program
The First Signs educational and training program incorporates an integrated mix of mailings, public service announcements, press activities, training, research, and website at www.firstsigns.org, which provides essential developmental information, an explanation of the screening process, a systematic guide to each stage of the process, listings of available local and national resources, and links to research, books, articles, and programs nationwide. The program features the First Signs Screening Kit, which includes an educational video ("On the Spectrum: Children and Autism"), screening guidelines based on the practice parameter and endorsed by the American Academy of Pediatrics, highly validated developmental and autism screening tools, a pediatrics practitioner’s referral guide to Early Intervention, and a developmental milestone wall chart.

Currently, First Signs uses the M-CHAT in screening for autism. The following general developmental screening tools are among those used in the First Signs program, although new tools, both for general developmental and autism are evaluated constantly.

Parents Evaluation of Developmental Status (PEDS) is a parent questionnaire which is 70 percent to 80 percent accurate in identifying children with disabilities from birth through eight years. It can be administered by a wide range of health care professionals or office staff.

Ages and Stages Questionaire (ASQ), developed by Diane Bricker, Ph.D. and Jane Squires, Ph.D. identifies children four months through five years experiencing developmental delays. It is a series of questionnaires that works well when used to stimulate conversations with parents or caregivers about a child’s development and any concerns they may have.

Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist (CSBS DP), developed by Amy M. Wetherby, Ph.D., CCC-SLP, and Barry M. Prizant, Ph.D., CCC-SLP has 24 multiple choice questions to be completed by a parent or caregiver. It is used to identify developmental delays in children from six through twenty four months of age.

Pervasive Developmental Disorder Screening Test - (PDDST)
The PDDST is a screening tool that can be used in multiple settings. Stage 1 is to be used in a primary care setting, Stage 2 for developmental disorders, and Stage 3 in a specialty clinic for children with ASD/PDD. It consists of a checklist of core areas of dysfunction and ASD/PDD based on parental report. The PDDST is designed as a screening test and is a parent report measure. As such, it does not constitute a full clinical description of early signs of autism but does reflect those early signs that have been reported by parents and correlated with later clinical diagnosis. (Bryna Siegel, Ph.D., (2001) University of California, San Francisco)

Psychoeducational Profile - Revised
The PEP-R offers a developmental approach to the assessment of children with autism or related developmental disorders. It is an inventory of behaviors and skills designed to identify uneven and idiosyncratic learning patterns. The test is most appropriately used with children functioning at or below the preschool range and within the chronological age range of six months to seven years. The PEP-R provides information on developmental functioning in imitation, perception, fine motor, gross motor, eye-hand integration, cognitive performance, and cognitive verbal areas. The PEP-R also identifies degrees of behavioral abnormality in relating and affect (cooperation and human interest), play and interest in materials, sensory responses, and language. The Adolescent and Adult Psychoeducational Profile (AAPEP) extends the PEP-R to meet the needs of adolescents and adults. (Schopler, Reichler, Bashford, Lansing, & Marcus, 1990)

Adolescent and Adult Psychoeducational Profile - (AAPEP)
The AAPEP extends the PEP-R (see description above) to meet the needs of adolescents and adults. (Mesibov and Schopler, (1988), Pro-Ed)

FUNCTIONAL ASSESSMENTS

Real Life Rating Scale
The Real Life Rating Scale assesses function of 47 behaviors. It can be used to monitor the effects of treatment in multiple environments and can be repeatedly used without affecting intra-observer reliability. (RLRS, Ritvo, Freeman, Yokota, & Ritvo (1986)

Medical Intervention for Individuals with ASD/PDD

Medical areas to be addressed include:

ACCIDENTAL INJURY
Increased rates of accidental injury can result from many of the more specific behavioral abnormalities. Social avoidance can cause excessive running. Sensory issues can cause ingestion of nonfood items or accidental burns/lacerations. Absence of a sense of danger can place the individual in potentially harmful environments. Monitoring and preventive anticipation are important.

SLEEP
Sleep difficulties are quite common in individuals with ASD/PDD, occurring in up to 70%. These include problems with sleep onset, night waking, and early waking. Sleep problems can be behavioral in nature, reflective of an underlying organic disorder or a combination of both. Because sleep problems can disrupt family life, they should be addressed aggressively. Behavioral strategies to ensure good sleep hygiene should be established. Medical interventions for individuals who have organic sleep disorder include further testing and possible use of medications. Since seizures can disrupt sleep, an EEG should be considered in the appropriate context.

FEEDING/NUTRITION
Individuals with ASD/PDD often display a limited variety of food preferences. This may be due to refusal to transition between textures, unwillingness to try foods of a particular color or texture, increased sensory sensitivity, or difficulties related to mealtime. These food preferences may be a reflection of the rigidity with which many of the individuals function. Their parents perceive their food choices as unhealthy or too limited. With slow introduction of healthier food choices, the individuals can generally be encouraged to try new foods. Under nutrition and overt malnutrition are rarely seen. A wide variety of dietary supplements and elimination diets are informally reported to improve or reduce many of the unfavorable behaviors seen in these individuals. At this time, there are no conclusive scientific studies to support the use of these dietary interventions. Individuals with pica (eating non-edibles), coprophagia or obsessive-compulsive symptomatology manifesting as food or eating rituals should be referred for evaluation. Parents of children who experience these difficulties should consult with a professional (SLP, OT, psychologist, registered dietitian, nutritionist, etc.) who has experience working with feeding issues in these children.

STEREOTYPIES
Simple repetitive behavior characterizes much of the play of young children with ASD/PDD. This can consist of looking at bright objects, listening to repeated sounds and vocalizations or repetitive motor mannerisms. High rates of stereotypies can interfere with adaptive learning in school and in the community. Stereotypies may persist into adulthood. They are more common and refractory in people with ASD/PDD and multiple, often undiagnosed, sensory deficits and those with greater degrees of mental retardation. They are often not responsive to medication.

SEIZURES
Children with ASD/PDD are at increased risk for the development of seizures with up to 20 - 30% prevalence by adulthood. The types of seizures are no different from the regular pediatric population. There should be a low threshold for obtaining an EEG on children who are exhibiting activity suggestive of seizures. Treatment with anticonvulsant medication depends on the seizure type and frequency, with decisions based on individual need.

DENTAL CARE
According to American Academy of Pediatrics guidelines, all children should be seen by a dentist for routine cleaning and evaluation by age one or within six months of the first tooth eruption. The same guideline holds true for children with ASD/PDD. The treating dentist should have experience working with children with special needs, particularly if sedation is to be used. Parents should strive to teach good dental hygiene at an early age since the sensory aversion associated with tooth brushing may make it difficult, if not impossible, to teach and implement brushing skills at an older age.

SENSORY ISSUES
Many children with ASD/PDD show differences in their responses to various sensory stimuli. They may have increased or decreased awareness to a particular stimulus. Sensory issues may contribute to problematic behavior. At times, stimulus sensitivity may be a manifestation of an underlying condition such as anxiety mood disorder and will improve with treatment of the condition. While anecdotal reports of benefit from specific interventions such as sensory integration therapy or a "sensory diet" are widespread, available study results are limited by the small sample size and further research is warranted. (For more information, refer to Sensory Motor Processing)

PUBERTY
Several issues occur during adolescence that may require assessment and monitoring. These include an increased incidence of epilepsy, especially complex partial seizures, mood disorders (depression and bipolar disorder), aggression, masturbation and increased interest in sexuality issues. Interventions are dependent on the underlying condition and include behavioral and pharmacologic treatment. Developmentally appropriate instruction about sexuality and issues such as menstruation and understanding of choices in areas such as birth control are important. (For more information, refer to Sexuality)

PSYCHIATRIC DISORDERS
The core diagnostic component of stereotyped, repetitive behavior and preoccupations, which can have obsessive-compulsive features, may be amenable to pharmacologic intervention. In addition, individuals with ASD/PDD often develop associated or secondary psychopathology (emotional, mental, or behavioral) that may be responsive to treatment. The first line of treatment for most of these problems is behavioral, however in some cases, supplementation with medication is indicated.

Co-morbid disorders are other medical conditions that are associated with and occur in this population at a higher rate than the normal population. These include:

ATTENTION DEFICIT/HYPERACTIVITY SYMPTOMS
Impaired ability to attend to some portions of the environment is characteristic of children with ASD/PDD. This can be manifested by poor discrimination learning, focusing on unusual or partial cues needed for an adaptive response, and rapidly shifting attention, which may be associated with increased general activity. Some children with ASD/PDD manifest more of these hyperactive and inattentive symptoms than others. Although attention-deficit/hyperactivity disorder (ADHD) diagnostic criteria exclude the presence of autistic disorder, the target symptoms may sometimes respond to the same treatments as ADHD in the general population.

ANXIETY
In addition to the impaired social interaction characteristic of ASD/PDD, some children will avoid social contact that results in high levels of anxiety (social anxiety). Generalized anxiety and anxiety secondary to interference with rituals or routine can also be problematic. Specific aversions (fears/phobias) can grow to debilitating proportions and prevent participation in formerly preferred activities. These anxiety disorders can respond to behavioral and/or pharmacologic treatment.

OBSESSIVE/COMPULSIVE AND SEVERE RITUALISTIC PATTERNED BEHAVIOR
Compulsive behaviors and rituals are frequently seen in individuals with ASD/PDD. They can develop from narrow preferences or simple stereotypies. Excitement often accompanies ritualistic behavior. Attempts to obstruct or distract a person with ASD/PDD from pursuing patterned behavior may easily elicit explosive reactions or aggression, possibly anxiety-driven. When OCD (obsessive/compulsive disorder) features are present, they may respond favorably to appropriate behavioral and/or pharmacologic interventions.

SELF INJURIOUS BEHAVIOR
Self-injurious behavior (SIB), such as head banging, picking, biting, and self-hitting, occur in individuals with ASD/PDD, especially those with mental retardation and impaired communication ability. Investigation of potential triggers/causation is mandatory. Intervention may be behavioral and/or pharmacologic, depending on the suspected underlying reason.

TICS
Tics are irregular, repetitive muscular contractions which may be patterned enough to result in apparently meaningful behavior. Tics vary greatly in severity. Some clinicians report a greater-than-chance co-morbidity of tics and Asperger Disorder or PDD-NOS. Mild, non-impairing tics need not be treated. More severe tics can be disabling and may respond to medication.

AGGRESSION
While a certain amount of aggressive behavior is common in all children at various ages, children with ASD/PDD tend to express these behaviors more frequently and with greater intensity. Tantrums are common in young children with ASD/PDD. Oppositional Behavior is common in older children and adults. Tantrums can persist and elaborate into dangerous self-injury, aggression, and property destruction. Reasons for aggression are varied. Intervention is dependent on the suspected underlying triggers or causes. (For more information, refer to Functional Analysis of Behavior and Behavior Interventions)

MOOD DISORDER
Loss of interest in usual activities, unexplained fatigue, change in sleep habits (increase or decrease), change in appetite (increase or decrease), change in concentration/cognition, and signs of distress, such as moaning or crying for no apparent reason, may reflect clinical depression. A person need not show all possible signs of depression to qualify for the diagnosis, but should have more than one. The diagnosis should be especially suspected when a recent loss was sustained, although, because of their core deficits, persons with ASD/PDD may not appear as bereaved by death of a family member as would be expected and might be more affected by loss of an object. Decrease in sleep time, increase of activity level, unprovoked aggression, disinhibition (e.g., sexual), increased appetite, irritability, and giddiness or elation, especially if cyclical, may suggest bipolar disorder. Again, a person need not show all signs and symptoms. Sometimes the main clue is a cyclicity of behavior of any kind (such as aggression, bolting, SIB), often preceded by a few nights of unaccustomed sleeplessness. All individuals with suspected mood disorders should be referred for further evaluation and treatment.

Additional Interventions

MEDICATIONS
Like any treatments, medications should be reviewed at every follow-up visit. A variety of medications have been described for individuals with ASD/PDD and several have been researched. However, there is no one medication that works for every person with ASD/PDD. The medication treatment of an individual with ASD/PDD needs to be symptom specific. Hyperactivity, sleep problems, obsessive tendencies, anxiety, aggression, and self-injury are some of the symptoms that may be targeted with specific medications. Medications should be given on a trial basis with close monitoring of positive and negative effects. Since there are few objective measures of a person’s response to a medication, reliance on subjective information (parent, teacher and caregiver reports) is common. The observations of parents and caregivers should be systematically collected by logs, charts, scales, or other accepted behavioral documentation. Occasionally, a trial of medication tapering and discontinuation is a way to determine its efficacy and/or whether it is still needed.

ALTERNATIVE THERAPIES
Interventions have been proposed based on theories of autism causation such as heavy metal poisoning, dietary factors, and auditory hypersensitivity. While anecdotal reports of intervention efficacy exist, there is no reproducible scientific research to support these claims of improvement outside of the possible impact of the placebo effect. If a trial of an alternative therapy is undertaken, one should ensure that the potential side effects will not harm the individual and that the trial will not impede the implementation of other proven treatments.

ESSENTIAL COMPONENTS OF INSTRUCTION

Considerations

DEFINITION OF "CURRICULUM"
John Dewey referred to curriculum as ‘...a continuous reconstruction, moving from the child’s present experience out into that represented by the organized bodies of truth that we will call studies ...’ (The Child and the Curriculum, pp. 11-12). This definition remains applicable to today’s educational challenges. Building on Dewey’s main points, curriculum is defined as an organized program of instruction designed by a team of professionals that responds to the changing needs of individuals and supports them toward independence and lifelong learning. This definition does not refer to a specific methodology, commercial product or author’s invention.

There are numerous methods or instructional strategies that are specifically designed for use with individuals with ASD/PDD. Professionals may incorporate a variety of approaches into instruction, but it is critical that it is:

• Matched to the strengths and needs of the individuals
• Modified as individuals change
• Effective in supporting independence and learning
• Aligned with state adopted content standards

LEARNING STYLES OF INDIVIDUALS WITH ASD/PDD
Individuals with ASD/PDD have the capacity to learn a variety of concepts and skills. However, because of unique communication and sensory motor processing issues, it is critical that instruction is designed with their individual learning styles in mind. Learning styles are based on:

Individual Strengths: Individuals with ASD/PDD may exhibit varied skills (e.g., visual, memory, music). These strengths may dictate an individual’s most effective mode of learning.

Individual Interests: Individuals with ASD/PDD may focus on specific topics of interest. This focus may allow them to develop a unique perspective, a specific skill, or a depth of understanding. Therefore, it is important to support and expand areas of interest and not extinguish them. Indeed, these interests can lead to meaningful leisure activities and employment outcomes.

Individual Motivators: These motivators come from every person’s need to derive reward for pursuits and interactions. Teachers, through instruction, build in assumptions of successful motivators such as grades, praise, stickers, etc. It is important to identify, with the help of family and the individual, the motivators that will provide incentives toward learning. Individuals with ASD/PDD often have unusual motivators that include completion of tasks, sensory-based stimuli, special interests, tactile-based stimuli, pace of activity, etc. Teachers need to understand and tolerate motivators that will not inhibit the learning environment.

Communication Style: Individuals with ASD/PDD have unique communication abilities and difficulties that may impair the teacher in recognizing the effectiveness of the process. The communication process can be made difficult because professionals may assume individuals do not understand and then make conclusions based on individual input or non-input. In teaching, individuals must communicate back understanding to the teacher. Teachers who are most effective in the communication process use multiple strategies simultaneously such as visual, auditory, written, symbolic, etc.

Sensory Motor Processing: Sensory motor proficiency involves the taking in of information from one’s body and the environment through a variety of sensory channels, interpreting/understanding these sensations, and developing a response to them. Sensory systems include auditory, visual, tactile, proprioceptive, vestibular, olfactory, and gustatory. Individuals with ASD/PDD may rely heavily on one or two sensory channels to compensate for deficits in other modalities. Preferences for specific sensory systems may therefore result in learning styles that are different from typically developing peers. For example, individuals may need to pair a motor activity with learning new material such as isometric exercises paired with multiplication tables.

Pattern of Skill Development: The premise of instruction is to teach in a sequential pattern of skill development. Individuals with ASD/PDD may have highly developed skills in one area and be delayed in others. Professionals should not assume that with a highly developed skill there are not gaps in learning. Teachers may need to teach holistically rather than sequential levels. Learning need not be linear to be understood.

Social Understanding: This is the ability for the individual to read social cues and the context and behave accordingly. Typically, social situations for individuals with ASD/PDD are often very stressful. Teaching techniques that rely on social situations may cause stress with individuals with ASD/PDD because of the reliance on social relationships. Individuals may have an inability to participate appropriately in the context of class discussions.

In conclusion, instructional strategies should be based on individual learning styles and should take into consideration and capitalize upon the aspects of unique learning styles.

ISSUES OF ASSESSMENT
The purpose of assessment is to develop instruction appropriate to the needs of each individual. Federal and state guidelines require assessment in the following domains:

• Cognitive
• Social/Emotional
• Academics
• Communication
• Vocational/Occupational
• Adaptive Behavior

However, assessments of individuals with ASD/PDD must also address areas of strengths, interests, and sensory motor abilities in order to get valid information on which to base instructional strategies. Emphasis on these additional areas will facilitate the assessment process itself and provide critical information for developing the individual’s learning. Assessments, whether ongoing or part of a multi-factored evaluation (MFE), need to take into consideration the unique learning style of the person with ASD/PDD (reference section on Learning Styles of Individuals with ASD/PDD). Assessments/evaluations should include information from the parent(s); data from previous interventions; criterion-referenced assessments; curriculum-based assessments; standardized, norm-referenced tests; structured interviews; and structured observations. On the other hand, most norm-referenced tests have limited usefulness in curriculum development. Regardless of the tools used, person(s) conducting the assessment must have a firm understanding of autism in order for the results to be valid.

Elements that will help to optimize the results of the assessment process include previous familiarity with individual, shorter test periods over multiple sessions, advance notice to individual prior to testing, and sensory motor preparation for optimal level of alertness.

(Reference IDEA Partnerships Council for Exceptional Children (CEC) document called "Making Assessment Accommodations: A Toolkit for Educators" (Document #P5376) and the sections on Communication, Sensory Motor Processing, Functional Analysis of Behavior and Behavior Interventions, and Community Transition)

ASPECTS OF A LEARNING ENVIRONMENT
Any instruction must include a carefully planned environment that is predictable, structured and appropriate for the sensory motor needs of the individual. Environments, including the regular classroom, resource room, community, and home, can be engineered to support the degree and type of structure that the individual requires. (Reference sections on Communication, Sensory Motor Processing, Predictability & Structure, and Generalization of Skills)

Learning and behavior may be enhanced by physical space modifications that include visual barriers, reduced visual or sound distractions, temperature adjustments, preferential seating, and visual organization of material. (Reference Functional Anaylsis of Behavior and Behavior Interventions)

Focus of Intervention - All Ages

The following areas will increase the individual’s ability to benefit from the educational experience and become more competent and independent adults.

ATTENTION
Purpose - Increase awareness of others, develop appropriate learning processes, establish attention to critical task stimuli, and reduce over-selective attention

Target Areas:

1. Acknowledgment of external world
2. Sustained attention (attending on a regular basis)
3. Saliency (looking at what is important)
4. Joint attention (attending with people)
5. Attention shifting (flexibility in attending) event to event, object to object, object to person, and person to object

IMITATION
Purpose - Prepare for learning complex skills, enable observational learning from peers and build reciprocal interaction

Target Areas:

1. Pre-requisite to imitative learning is that it must be purposeful and independent
2. Attention to model: Imitation of movements, vocalizations, verbalizations, and gestures

COMMUNICATION
Purpose - Establish verbal or augmented communication skills; enhance social interaction as an initiator and responder; enhance comprehension of events and persons in the environment; provide appropriate alternatives to challenging behaviors with one to two backup systems

Target Areas:

1. Use and comprehend non-verbal communication (gestures, gaze and facial postures)
2. Use and comprehend non-verbal communication and primary vocabulary and simple sentence structures
3. Use and comprehend non-verbal communication and vocabulary and simple sentence structures and grammatical-parts of speech
4. Use and comprehend combined/multiple communicative means
5. Use communicative means for a variety of reasons (request, protest, comment, repair, etc.)
6. Use echolalia functionally
7. Increase use of spontaneous language
8. Continued vocabulary building, comprehension and use

SOCIALIZATION
Purpose - Establish social and affective contact with others

Target Areas:

1. Intentional and systematic introduction to social situations with initiation and respondent acts
2. Turn-taking - including non-verbal/vocal/verbal turns
3. Adult-child and child-child interactions
4. Sharing
5. Will be able to give help and accept help
6. Choice-making
7. Understanding other persons emotions and perspectives
8. Interdependence - be able to assist and accept assistance from others

COGNITION
Purpose - Enhance conceptual, problem-solving, and academic performance and executive function (flexible, strategic plan of action to solve a problem or attain a future goal)

Target Areas:

1. Utilization of multiple modes of learning concepts and skills (e.g., sorting, matching, classifying, problem-solving, categorizing, comparisons, ordinals, sequencing, temporal understanding, spatial understanding)
2. Understanding cause/effect
3. Abstract thinking
4. Humor

PURPOSEFUL PLAY/RECREATION/LEISURE
Purpose - Enhance cognitive, social and motor skills; enhance relationships between self and environment and improve appropriate use of unstructured time

Target Areas:

1. Intentional and systematic introduction of a variety of play and leisure skills
2. Interaction/cooperation with peers
3. Leisure to include toys, games, sports, hobbies, creative arts (drama, music, writing, arts and crafts)

ESSENTIAL LIFE SKILLS
Purpose - Increase personal independence and create opportunities for greater community participation including independent living, working and recreating

Target Areas:

1. Transitioning within daily activities
2. Self-help: e.g., toileting, dressing-undressing, eating/feeding/drinking
3. Safety
4. Hygiene
5. Gross and fine motor coordination
6. Managing sensory stimuli
7. Purposeful communication
8. Productivity of a task
9. Flexibility of a task

Additional Focus Areas - Ages Six Through Twenty One

In addition to the above areas, the following areas should be included in programs for individuals, ages six though twenty one:

TRANSITION (REFERENCE COMMUNITY TRANSITION SECTION)
Purpose - Facilitate integration of the individual into the community in terms of work or post secondary education, recreation, and residence

Target Areas:

1. Generalization of learned skills to the next environment
2. Exploration of areas of interest or strength
3. Selection of community options including work, leisure, residence, and post-secondary activities

SEXUALITY
Purpose - Assist the individual to understand and express sexuality in an acceptable and appropriate manner

Target Areas:

1. Acquire skills which assist in the development of friendship
2. Develop personal health and hygiene
3. Understand changes in the body and how to manage the changes
4. Develop appropriate outlets to express sexuality

BEHAVIOR
Purpose - Develop functional behaviors that are acceptable in the school, work, and community environments

Target Areas:

1. Develop effective means to communicate needs, wants, desires, and emotions
2. Develop a repertoire of expected social behaviors for environments where the individual lives, learns, works, and spends leisure time
3. Develop skills and abilities which lead to positive and acceptable behaviors

Essential Components of an Instructional Program

In recent years, professionals and families have been presented with encouraging data and reports of successful interventions for individuals with ASD/PDD. Although research documents a number of programs demonstrating substantial benefits for individuals with ASD/PDD, differences exist in reference to funding, location, degree of family and community involvement, available resources, and program content and structure.

The purpose of the following section is to provide educators, administrators, individuals, and families with a framework and structure for program development and evaluation.

EARLIEST INTERVENTION
The standard "earlier is better" may serve as a particular advantage for children with ASD/PDD (Lovaas, 1987; McClannahan & Krantz, 1993). However, identifying and diagnosing ASD/PDD at any age allows professionals and families to address the challenges associated with ASD/PDD and develop an effective program.

Most educators and families agree with the position that intervention programs are more effective when begun at the earliest age possible.

Services provided in these programs achieve the following outcomes for individuals with ASD/PDD and their families:

• Provide the opportunity to intervene to minimize the development of interfering behaviors and/or
• Facilitate gains in attention, imitation, communication, socialization, cognition, leisure skills, work skills secondary disabilities and other essential life skills
• Help support the development of a young person with ASD/PDD, establish social networks, and reduce family stress
• Increase independence and decrease likelihood of social dependence
• Teach functional communication strategies
• Reduce societal costs for services that will be needed later in life
• Include the individual with ASD/PDD and the family in intervention planning and implementation to promote generalization and maintenance of skills

INTENSITY
Although the duration of intervention (e.g., number of hours per day or per week) and number of contexts (e.g., home, school, community) encourages the debate of what constitutes sufficient intensity, what is agreed upon is that more intense quality intervention generally results in better outcomes and that the intensity of interventions is determined by the unique needs of each family and individual.

The following general suggestions may be used to guide decision-making:

• Assess the individual’s needs for year round intervention programming across contexts
• Assess the need for individual vs. group programming
• Focus on assessment driven individualized programming and instruction
• Assess individual and family’s strengths and needs in regards to programming
• Stress ongoing support and staff development of teachers, support staff, and related services working with individuals with ASD/PDD
• Provide individuals with ASD/PDD continuity of programming across people and settings as agreed upon in the IEP or IFSP
• Recognize that effective intervention for ASD/PDD requires ongoing assessment and ongoing individualized programming

PREDICTABILITY AND STRUCTURE
Individuals with ASD/PDD benefit from an environment that incorporates a structured program tailored to meet their individualized needs. A thorough structure also enables professionals to stay in tune with daily events that may create stressful situations for the individual. Professionals and families need to collaborate to develop effective goals and objectives to create an environment that promotes continuity, cohesion and consistency to best meet individual needs and enhance their independence. Uniform and comprehensive training of these transdisciplinary teams needs to be ongoing and consistent to support successful educational programming.

To provide the necessary organization in the educational setting, the following components are critical when providing predictability and structure.

Teaching the concept of "Time" and the Passage of Time

• Use calendars
• Create visual daily schedules (to prepare in advance for regular and unexpected changes in routine)
• Pairing routines, activities and transitions utilizing an analog clock The functional and organizational layout of the environment
• Provide a safe environment (e.g., adult/child-individual ratio, exit doors)
• Visually identify all areas of the room (using pictures and/or words)
• Use natural boundaries, such as desks, files, and partitions, to create specific areas
• Clearly define and visually represent "Rules of the Room"
• Use environmental modifications to help manage and tolerate sensory stimuli (Reference Sensory Motor Processing)

Utilize materials that enhance play, leisure, academic and vocational activities

• Use hands-on materials and manipulatives
• Use assistive technology (computers, augmentative devices, switches, assistive listening devices, calculators, etc.)
• Use multiple modalities (e.g., visual, auditory, tactile) to provide information and structure

Teaching social skills to develop environmental awareness

• Clearly define and visually represent "Rules of the Room"
• Provide social awareness using social skill development activities
• Teach how to read "body language" and gestures
• Teach the understanding of empathy and humor
• Recognize emotions and situations where emotions are expressed

GENERALIZATION OF SKILLS
Typically, young children/individuals will learn incidentally from the activities and persons in their environment and will generalize these observed skills with minimal effort. However, for individuals with ASD/PDD, it is difficult to utilize a learned or observed skill in another setting. They do not necessarily model or imitate observed behaviors and may not understand that a "skill" learned in isolation can and should be generalized in other environments. For this reason, programming for appropriate generalized outcomes has long been recognized as a critical component of interventions for individuals with ASD/PDD.

The need for generalization should be considered across a variety of circumstances, e.g., across time, settings, persons, and behaviors. Time refers to maintaining the use of a learned skill after the teaching process has stopped. Across settings refers to the use of a learned skill in settings outside the teaching environment. Persons refer to the use of a learned skill with and without the individual who taught the skill and that the skill can be demonstrated with others.Generalization across behaviors refers to changes in untaught skills which are related to the skill being taught, e.g., teaching an individual to say "Hi" not only increases the use of that word upon greeting someone, but also increases other greeting behaviors such as waving, making eye contact, etc., which are not being directly taught. These forms of generalization all need to be considered in any program designed to teach new skills to an individual with ASD/PDD and specific strategies to promote generalation need to be incorporated into the teaching process.

However, some individuals may over generalize, which is an over application of a concept (product of over-selectivity). For example, if they determine that the critical feature of an animal is four legs and are not identifying with the other features, then the individual will assume that all four-legged creatures are the same animal.

The following are a number of teaching strategies to assist in fostering generalization.

• Skills taught in an instructional environment should lead to naturally occurring, positively rewarding consequences in everyday environments. For example, learning to make a peanut butter and jelly sandwich results in eating an enjoyable snack at its completion.
• Teaching a skill in a variety of situations, settings, or with multiple teachers helps promote generalization of a skill. Thus, teaching of toileting skills in a variety of restroom configurations with several different people assisting can increase toileting skills in most community settings.
• Bringing features or common elements of the everyday environment into the teaching situation helps to generalize skill use in that everyday environment. For example, teaching shoe tying using the individual’s shoe and shoelaces instead of common string or pipe cleaners would promote generalization to the real world task.
• Once a behavior has been learned to a consistent high level of performance, one can shift to intermittent rewards so that the skill is more resistant to being extinguished if rewards are not given frequently on some occasions in the future.

Teaching self-management techniques can be useful for promoting generalization. Self-management involves learning to prompt and reward one’s own behaviors in various situations outside of direct treatment.

FUNCTIONAL ANALYSIS OF BEHAVIOR AND BEHAVIOR INTERVENTIONS
This section describes issues related to the behavior of individuals with ASD/PDD. It includes descriptions of common behavioral issues and causes. Because behaviors are functional for the individual, it is important to understand the intent of the behavior before applying an intervention. This section focuses on understanding behavior and intervention strategies. It is best used in conjunction with the rest of the document because disruptive behavior has a cause/effect relationship with all other areas of development, inclusion in the community and life experiences. Difficulty communicating needs, a lack of understanding expectations, or a negative reaction to the environment, can contribute to disruptive behavior. Appropriate social behavior is necessary for learning, interacting with peers and involvement in the community.

In our society, behaviors are often only talked about in a negative context. "His behavior is interfering, disruptive, or self-defeating." It should be noted that persons with ASD/PDD may have a dramatically narrower repertoire of behaviors, particularly in social situations. The effort to reduce maladaptive behaviors needs to be offset by equal energy to focus on teaching the individual new, functional, and appropriate behaviors.

Behaviors Serve a Function
Disruptive and disturbing behaviors are sometimes manifested by individuals with ASD/PDD. It is important to consider that behaviors can be very functional for the individual, yet may result in negative outcomes. Understanding the behaviors of any individual is very complex. Behaviors vary as a result of internal (e.g., emotion, puberty, maturation, aging, nutritional changes, overall health, sensory sensitivity) as well as external factors (e.g., changes in environment, social pressures, sleep deprivation, behavior of others, changes in school or personnel). Teachers and caregivers need to view behaviors as communicative rather than an intentional effort to disrupt.

It is important to identify the antecedents of a behavior and the consequences that reinforce it. This information can be used to change the behavior by altering the antecedents and/or the consequences. This operant conditioning approach is often used in combination with other supports and strategies.

To better understand the complexities of behaviors and to identify better interventions, one can also use a systematic procedure called Functional Behavior Analysis (or Assessment), which incorporates the operant conditioning approach.

Functional Analysis of Behavior and Behavior Interventions
The premise of a Functional Behavior Analysis (or Assessment) is that all behavior serves a purpose. Behavior often achieves some desired goal or goals. The goal or goals may be escape/avoidance, control (including meeting one’s own sensory needs), attention, and/or getting a specific object, as well as an attempt to communicate.

Therefore, the goal of any behavioral intervention program is to teach adaptive behaviors and to prevent the development of unwanted or inappropriate behaviors. Research has shown this to be an effective strategy in individuals with ASD/PDD and other developmental disorders. Functional analysis focuses on the "ABCs" of behaviors (antecedent, behavior, consequence) as a means to understand the purpose or function of the behavior. Such analysis facilitates the development of needed skills and, as more functional and socially appropriate behaviors are learned, problem behaviors are reduced or eliminated. The use of behavioral analysis is a mainstay of successful behavioral intervention strategies for individuals with ASD/PDD.

Typically, functional analysis proceeds through the following steps:

• The target behavior (skill to be learned or problem behavior to be eliminated) is defined in terms of observable, measurable behaviors.
• Identify the behavioral antecedents that are needed for the achievement of a new skill or that can trigger/encourage a problem behavior. Common reasons for the failure to attain a learning goal include absence of foundational skills, lack of understanding of the purpose of the activity, internal or external distractions, or inadequate reinforcement strategies. Factors that underlie problem behaviors may include absence of adequate communication skills, environmental events that trigger the behavior, and adult responses that inadvertently encourage the unwanted behavior.
• An intervention to teach a new skill or reduce a problem behavior is developed logically from the information gathered during the functional analysis. The strategy should consider the purpose of the desired skill or the problem behavior, the individual’s developmental level, the need for structure and consistency, the intervention setting, and the need for collaboration between parents and professionals in addressing the problem.
• Consequences that strengthen or weaken the occurrence of the target behavior must be identified. Particular attention must be given to individual differences in reinforcer effectiveness among individuals as well as the schedule for the occurrence of the consequence.
• The impact of the intervention strategy is evaluated through regular reviews of objective data. Interventions are then adjusted or revised accordingly.

(For detailed information regarding Functional Behavior Assessment, please see Appendix IV)

Behaviors Change Over Time
Challenging behaviors that an individual exhibits as a child may disappear with maturity or behavioral challenges may become more prevalent due to changing conditions. Sometimes the behaviors an individual exhibits do not change but are perceived differently by others as the individual ages and physically matures.

It is important that the behavioral history of the individual be well understood by all persons participating in the care and education of the individual. His or her unique reactions to common as well as novel situations and intervention strategies that have been successful are important considerations in designing successful interventions.

Behaviors Require Brainstorming and Teamwork
Successful intervention for challenging behaviors requires all persons involved with the individual (the team) to work together to meet the needs of the individual with ASD/PDD. Flexibility is required on the part of all team members to establish and maintain communication with each other and to apply consistency in implementing the agreed upon intervention(s). The team must assess the situation, identify the individual’s needs and abilities and implement strategies to assist the individual in learning and using appropriate behaviors. The process of assessing, teaching and learning appropriate behaviors may sometimes proceed quickly or may require a long period of time, the involvement of many people to assist, and the systematic testing of a variety of strategies.

There is a dynamic relationship between the educator, parent, others involved and the person with ASD/PDD. Priorities and goals of each are contributors to problems (lack of unity and confusion) and successes (cooperation, compromise, and consistency). Individuals working together as a team must be willing to share resources and personal limitations. They must be willing to compromise. They must be willing to make the most of the creativity that can exist within the team. Be prepared to do things differently.

Influences on Behavior
Behaviors are influenced by the characteristics of ASD/PDD and by environmental issues. Some behavioral influences include:

Stress/Anxiety - Stress and anxiety are often key factors triggering behaviors characteristic of people with ASD/PDD. There are many worries that lead to stress. Such worries may include changes (or anticipated changes) in schedule, interactions with peers, and pressure to perform. Stressors need to be understood, monitored and controlled with care and respect for the individual’s perception and future needs. Individuals with ASD/PDD may view causes of stress differently and have varied reactions to stress. All caregivers/ providers must be aware of and manage their own stress levels. Individuals with ASD/PDD experience awareness of and often negative reactions to the stress of others.

Physiological Factors - Challenging behaviors may occur more frequently or intensely when physiological difficulties are present. These factors may include lack of sleep, medication changes, hunger, and illness (chronic or acute). An individual with ASD/PDD may not understand why he is experiencing these difficulties and/or may not be able to express these concerns in a functional manner. The functional analysis must assess if these factors are present and their effect on the behavior.

Sensory Sensitivities - Many individuals with ASD/PDD present with sensory sensitivities and/or sensory preferences that are very different from the typical population. Behaviors may occur when an individual encounters a sensory experience that is unpleasant or painful. These sensitivities may be auditory, tactile, taste, visual, or others. Additionally, the sensory experiences that trigger a behavior for an individual with ASD/PDD may be subtle and generally uneventful for others. At times, simply the anticipation of the experience can trigger a behavioral response. The functional analysis must consider the unique sensory profile of the individual when determining the function of a behavior.

Finally, successful interventions targeting specific challenging behaviors may vary greatly and include a blend of interaction strategies, structure, and medical support. Some problems may need to be tolerated or set aside for a time while focusing on more dangerous or interfering behaviors (e.g., Pick your battles!). Successful interventions sometimes require an adjustment period, during which the individual’s behavior may seem more challenging than it was prior to intervention. Seek agreement and commitment from all team members and allow interventions to work by implementing them consistently and giving them time.

This represents a sampling of frequently encountered behaviors and suggested strategies. These should not limit other creative alternatives that consider the uniqueness of each individual.

COMMUNICATION
The Communication section describes the unique patterns of communication associated with individuals with ASD/PDD. Included are ideas on how to assess the purpose of communication and strategies for improving communication. This section is best used in conjunction with the rest of the document because the ability to communicate affects all other areas of learning, socialization, and behavior and they in turn are affected by communication abilities. The ability to communicate one’s feelings and thoughts to others has a profound effect on quality of life both immediately and long-term. Without an effective communication system, it is very difficult to navigate through life. In addition to individuals who have obvious communication challenges, there are many individuals with ASD/PDD who may only appear to be capable communicators. In fact, those individuals may not be effective communicators and that can limit their ability to meet their potential.

Communication difficulties both verbal and nonverbal are inherent to the diagnosis of ASD/PDD. The normal developmental sequence of communication development is disrupted in persons with ASD/PDD. Communication skills can range from non-verbal, gestural, the use of single words to verbal conversation and may include the following communication difficulties: Perseveration (repetitive verbal and physical behaviors), Echolalia (immediate and/or delayed "echoing" of words, music, phrases or sentences), Hyperlexia (precocious knowledge of letters/words or a highly developed ability to recognize words without full comprehension) and to a lesser degree, Dactolalia (repetition of signs), pronoun reversals, inappropriate responses to yes/no questions, and difficulty responding to "WH" questions.

Communication difficulties impact all other areas of learning, socialization, and behavior. When designing appropriate intervention strategies, it is important to understand the individual’s receptive (comprehension) and expressive communication skills. Stressful situations that increase anxiety often interfere with the individual’s ability to communicate. Difficulty understanding humor, idioms ("keep your eye on the paper"), sarcasm and other complex forms of verbal and written expression is common. Even the highly verbal individual may understand and use literal (concrete) language but have difficulty with abstract concepts. A person’s communication ability usually changes over time. Therefore, it is important to maintain an ongoing communication assessment from diagnosis through adulthood as this provides current information, which is necessary to support appropriate communication strategies.

It is important to understand the individual’s unique communication style/skills which leads to development of a method for communication. Supporting all forms of communication - verbal, signing, pictorial, augmentative devices (and often a combination of more than one) promote learning. In addition to the development of an effective communication system, consider use of the following modifications and strategies.

Modifications

• Decrease question asking and increase comments and descriptions of activities, emotions, and environments that the person experiences.
• The communicating partner needs to fully understand that situations, certain individuals, sensory issues and stress will affect the quality of communication and the communication intention.
• Modify the speaker’s language and provide visual supports if there is no response or undesired response to a direction or question.
• Allow time for auditory processing and formulation of information. For example, instruction and conversation may need to move at a slower rate.
• Develop a protocol to gain the individual’s attention. The protocol should include how to initiate joint focused attention.

Strategies

• Encourage meaningful imitation. Since imitation is one of the precursors to the development of functional language, build in ample opportunities for activities to develop imitative skills.
• Help the individual focus attention on the speaker. This will maximize the impact of any direction, question, or information.
• Determine the communicative intent and other possible functions of non-verbal and verbal behaviors to establish their meaning. For example, if a person hits when frustrated, teach an appropriate behavior that communicates that they are frustrated, reduce the frustration or both.
• Integrate communication strategies into all daily activities. Teaching communication strategies in a step-by-step approach, starting in an organized environment, will assist generalization to other environments.
• Use vocabulary and grammatical structure at the individual’s comprehension level.
• Consider using rhythm and music.
• Teach turn-taking and joint attention.
• Provide the individual with multiple opportunities to initiate interactions, make choices, and have peer-to-peer contact on a daily basis across all environments.
• Consider supporting receptive communication as well as expressive communication through both nonverbal and verbal methods: visual supports (object boards, pictures, gestures, sign language) and voice output communication devices.
• Facilitate the initiation of conversation and provide opportunities to practice language rather than waiting for the individual to initiate contact.
• During transitions from classes, buildings, work: offer a summary of successful communication strategies to appropriate personnel.

ASSISTIVE TECHNOLOGY
Assistive technologies are applications (either hardware or software) designed specifically to assist individuals with disabilities to overcome barriers. In compliance with IDEA, schools are responsible for determining what assistive technology(ies) is/are appropriate for an individual with a disability in order that the individual may receive a free and appropriate public education in the least restrictive environment. Assistive technology is defined as..."any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities" (IDEA). In addition, assistive technology services must be provided in order that the individual with a disability is able to successfully select, acquire, and use an assistive technology device.

The varied use of technological systems with individuals with autism spectrum disorder has received limited attention in spite of the fact that technology tends to be a high interest level for many of these individuals (Stokes, Wirkus-Pallaske, and Reed. (2000) Wisconsin Assistive Technology Initiative). Caution should be taken not to limit the consideration of assistive technology to expressive communication only. While augmentative communication devices can support a significant "breakthrough" for some individuals with ASD, there are many other ways in which to use technology within an educational program for individuals with ASD. These are categorized in several categories. Examples follow.

"No" Tech Tools

• No tangible item or material is involved
• Clear physical and visual boundaries
• Elimination of extraneous visual stimulation
• Proximity of staff to individual

Low Tech Supports
These require the individual or staff person to utilize an item that typically is not electronic or battery operated. These items are typically low-cost and easy to use.

• Dry Erase Boards
• Clipboards
• Three-ring binders
• Picture Symbol Cards
• Choice Board (no voice output)
• Ear Plugs
• Use of a pointer
• Visual Schedules and Routines

Mid-Tech Tools
These include battery-operated devices or simple electronic devices requiring limited advancements in technology.

• Tape recorder
• Timers
• Calculator
• Head Phones
• Assistive Listening Devices
• Portable Word Processor
• Simple Voice Output Devices

• Computer Software and Adaptive Computer Hardware
• Video Cameras
• Complex Voice Output devices

Educational teams should consider carefully the advantage of assistive technology in all aspects of the individual’s program. Inclusion of "low tech", as well as "high tech" tools should be considered. Finally, teams should identify how technology may assist the individual not only to effectively communicate, but also to access the general curriculum and to make progress on individual goals and objectives.

SENSORY MOTOR PROCESSING
This section describes issues in sensory motor processing for individuals with ASD/PDD. It includes a definition and explanation of terminology in order to provide a common understanding of the issues involved. It also includes practical strategies and guidelines for developing sensory supports in all environments. This section is best used in conjunction with the rest of the document because the individual’s ability to process sensory input from the environment affects all other areas of learning, socialization, and behavior.

Sensory motor processing challenges limit the experiences and environments in which an individual with ASD/PDD can function successfully. The identification of strategies to address these challenges can expand the opportunities for relationships, work and leisure in which individuals with ASD/PDD can participate.

Sensory motor processing involves the ability to take in information from the environment, organize it, make sense of it and formulate a response. Normally, this happens automatically. When the system is working well, we can screen out unimportant stimuli, pay attention, respond appropriately and move through the environment fluidly. When the sensory system is not functioning well (regardless of the reason), we may have difficulty paying attention and formulating responses that make sense. In addition, we may shut down or overreact to incoming stimuli and have difficulty moving safely and freely.

The senses that the brain uses to take in information include the well-known senses of sight, hearing, taste, and smell, and three other systems that are very powerful - the tactile, proprioceptive and vestibular systems. The tactile system involves information that comes from contact with the skin. Light touch can activate the fight-flight-fright response and deep pressure touch can calm the nervous system. The proprioceptive system registers where your body is in space through the joints, muscles and tendons. The vestibular system assists in balance, coordination and movement.

It is important to be aware that individuals with ASD/PDD will likely have difficulty in one or more of these sensory systems. For example, over-sensitivity to sounds, light, touch, or movement can indicate sensory defensiveness. This may be characterized by unexplained emotional outbursts, stereotypic behaviors such as rocking and pacing or fearful avoidance of contact with people and objects in the environment.

Recommended strategies for working with individuals who demonstrate defensiveness include:

• Avoid touching the individual without giving a verbal cue first
• Make boundaries around the individual’s workspace and establish each individual’s space as part of the classroom rules, using carpet squares, masking tape or furniture
• If the individual needs to be touched, use a firm but kind touch, rather than a light tap
• Decrease the amount of visual and auditory distractions in the room
• Provide structure and predictability
• Provide additional support during transitions between lessons and between places in the building

Other sensory challenges may result in problems filtering incoming stimuli, organizing the information and developing a response to it. This may be characterized by difficulty directing and shifting attention, maintaining alertness for a task and executing a sequence of steps to complete a task. Specific strategies must be tailored to the individual’s needs and challenges.

The following suggestions serve as guidelines when developing sensory supports in all environments:

• Determine individual’s tolerance/comfort with input from various sensory channels
• Identify behavioral indicators of excessive stimulation (e.g., covering ears or eyes with hands, body rocking, hand flapping, withdrawing)
• Conduct an environmental assessment to identify problem stimuli (e.g., lighting, noise, odors, textures, and limitation of personal space)
• Proactively modify the environment to accommodate sensory motor processing needs (e.g., reduce noise with sound absorbing materials, keep visual stimuli to a minimum, create study carrels and clear boundaries for work areas)
• Determine the need for appropriate sensory input throughout the day (e.g., deep pressure, movement, and materials to manipulate during instruction or work time)
• Provide opportunities for heavy work (e.g., activities requiring exertion) throughout the day. Examples include stacking/unstacking, pushing carts/trash cans, holding doors, washing chalkboards, crushing aluminum cans for recycling, and sweeping floors.
• Provide access to suspended equipment (e.g., swing in corner of classroom or gym) if indicated
• Incorporate movement activities and manipulative materials into instructional time and provide breaks for additional physical activities and/or sensory input as needed (e.g., exercises, walks, mini-trampoline)
• Schedule regular "sensory breaks" during the day as needed. Activities during these times may include joint compression/traction, using hand held objects that provide vibratory or pressure touch input, movement, or calming music.
• Provide opportunities for the individual to indicate a need for strong sensations or access to equipment at times other than what is regularly scheduled as part of the routine.
• Determine environmental/task modifications that may help in reducing the motor challenges facing the individual (e.g., desk/chair height, writing utensils, position/type of work materials)
• Allow the individual to stand at the chalkboard or an easel to work. Standing will provide needed input into trunk musculature that will help the individual stay alert and focused on the task.

A professional who is knowledgeable about sensory motor processing should be consulted for specific strategies for any individual. Generally, this professional is an Occupational Therapist.

SOCIAL DEVELOPMENT
Impaired social development is a cardinal feature of ASD/PDD. It ranges from complete indifference to others to atypically social to socially inappropriate. Social development is dependent on other areas of development, especially communication and sensory motor processing. Socialization requires communication skills in order to have successful social interactions and group experiences. In addition, the ability to seek out and enjoy the social interaction is dependent on the individual’s ability to focus on the interaction rather than coping with the environment. Being capable in social situations allows the individual to successfully engage in activities such as holding a job, maintaining a living situation and taking care of basic needs as well as improving the quality of life.

The social deficits in ASD are influenced by the individual’s age and severity of impairment. Usually the deficits are most severe in the young child with variable improvement over time that, in part, is influenced by cognitive potential, underlying etiology, if known, and co-morbid conditions. Social impairment has been defined by Lorna Wing as:

1. Socially aloof - ignore or avoid social interaction with indifference to peers and limited if any, response to simple stimulation.
2. Socially remote - little spontaneous social interaction with allowance of social approaches and limited passive involvement in activities.
3. Active, but odd - Attempt social approaches to achieve personal goals (needs or area of fascination) with little interest in the needs or responses of others.
4. Superficially social - Utilizes learned social scripts with ongoing deficit in true grasp of social rules and impact of actions.

These classifications are based on clinical observations. From a functional standpoint, they provide a basis for differentiating social impairments and monitoring an individual’s growth over time.

The lack of social understanding affects all social aspects of work, school, interpersonal relationships, recreation and community involvement that all play a part in the building of self-esteem.

Social skills may not generalize without specific training, therefore, it is important that social competence be reinforced in all environments (including the workplace), especially for those individuals who are in transition. Specific strategies and supports for social development and related skills must be provided to individuals with ASD/PDD.

There are several levels to consider when providing social strategies and supports. When assessing the social competence for individuals with ASD/PDD, it is important to look at the quality (content and meaning) of the social interactions vs. the quantity (amount) of social interactions. One individual may have difficulty tolerating others in their personal space while others may "get in your face" and talk incessantly on one or two self-interest topics. Supports need to be developed based on the strengths and interest of the individual. That is, one individual may need to learn social skills to initiate social communication in a one-on-one setting with introduction to social situations in small steps, whereas an individual with Asperger Disorder may need to have a repertoire of social topics to learn how to reciprocate and maintain social communication.

Assessment of social competence should include considerations, for example:

• Age of individual Sensory motor processing challenges
• Imitation skills
• Receptive and expressive language skills
• Cognitive abilities
• Individual’s interests and skills
• Environment where socialization occurs

(See Appendix IX - References and Resources, Social)

When developing social goals, the following areas need to be addressed:

• Imitation and joint attention (attending with others)
• Understanding personal space
• Acceptable environmental behaviors, such as not picking nose in public, bathroom etiquette, etc.
• Emotions of self and others
• Identification of emotions and where they occur
• How individual actions affect others
• Asking for help/assistance
• Slang, sarcasm, joking, teasing
• Initiating, maintaining and reciprocating social interactions
• Accepting rejection by peers
• Playing games, winning and losing graciously
• Turn-taking, waiting for turn
• The meaning of body language (includes facial and bodily gestures)
• Age appropriate behavior with the opposite sex, e.g., recognizing unwanted sexual advances and dealing with them appropriately, understanding appropriate sexual expression and seeking privacy for any sexual expression, finding appropriate ways of seeking and giving affection
• Typical peers’ understanding and successful ways to interact and support the individual with ASD/PDD
• Appropriate workplace behavior as a part of the transition from school to work. This includes the use of vocational language, how to take work breaks, dealing with the public, and working with superiors, subordinates and work peers. In many cases, the degree to which a person with ASD/PDD "fits in" with, and is accepted by, their work peers will determine their long-term job success. The employer may require assistance with appropriately introducing the person with ASD/PDD to the workplace and educating the workers with how to have a meaningful work relation with that person. On the other hand, once acceptance is gained from work peers, the person with ASD/PDD often has a very strong, vocal support network that greatly enhances the probability of their long-term job retention and success.

A number of strategies and supports are available to teach appropriate socialization and social understanding. Based on the assessment of social abilities, teaching of these social skills may occur in one-on-one, small group, large group or a combination of these teaching environments. Due to generalization issues, a plan should be developed and supported to expand socialization and social understanding into multiple environments.

Several broad categories of strategies and supports to consider include:

• Rehearsal - Scripting, Modeling and Practice
• Role Play
• Social Curriculums
• Social Skills Manuals
• Visual Supports
• Peer Models
• Structured Peer Supports

(For a complete list of resources, refer to Appendix IX References and Resources, Social)

Regardless of the environment used or the strategies selected, instruction in socialization and social understanding must be provided in a well-planned and systematic manner.

INTEGRATION WITH TYPICAL PEERS
(This section is not intended to be used for Least Restrictive Environment decisions).

Models of language and social interactions are an important component of a successful program for individuals with ASD/PDD. However, the mere presence of typical peers does not constitute successful social-communicative interactions. Coordinated efforts across school, home and community environments can assist to promote natural peer interactions. Families and professionals may focus on the implementation of a variety of strategies in these environments, including activities, routines, and situations to promote peer-peer interactions. When selecting strategies and coordinating a plan to support the individual with ASD/PDD in integrated activities, consider the following guidelines:

• Assess the person’s individual need for integration with typical peers. Provide a natural progression of integration (e.g., individual to segregated classroom to small group to large group instruction).
• Plan and schedule activities that promote integration and prevent segregated grouping.
• Continue to emphasize the acquisition of skills that will allow the individual to benefit from integration experiences.
• Include in the transition plan the commitment of all team members, assessment of placement options (evaluation of a individual’s learning style and teachers’ instructional style), skills the individual needs for integration, and training for instructor and support staff.
• Provide specific guidance to peers to recognize and respond to verbal and nonverbal communicative behaviors of the individual with ASD/PDD. Include strategies that focus on the peer’s ability to initiate, respond to, and maintain social-communicative interactions with the individual.
• Incorporate environmental supports (such as charts, cue card, directions) in conjunction with peer models or as alternatives to direct adult support.
• Determine the amount of time the individual should spend in the integrated setting.

ASSESSMENT OF PROGRESS
Assessment is vitally important for judging the effectiveness of any intervention. Progress assessment is especially critical for the population with ASD/PDD because they are resistant to many forms of intervention that are very effective with others. Therefore, treatments used for those with ASD/PDD should be held to standards of effectiveness and appropriateness that respect the values of parents and professionals to make a difference in the lives of these individuals.

The outcome of any intervention can be assessed in two ways:

1. Criterion Referenced - This method is useful when the desired outcome is known and well understood. Using a criterion-referenced approach to evaluate progress tells everyone that effective intervention has occurred when the goal is successfully achieved. In criterion references assessment, the various levels of evaluation must be considered carefully. The overall intervention program or strategy is judged on the basis of the achievement of the entire collection of goals and objectives. Progress on goals is assessed on the basis of achieving the interim objectives leading to their individual completion. Example: Can a child tie his own shoes?
2. Norm Reference or Standardized -Intervention can be judged in terms of change in a desired direction from some defined starting point according to some accepted standardized measure. This method of progress assessment makes it necessary to define the reference points very carefully. Progress is then determined on the basis of change in some or all of these measures. The minimum number of measures needed is two, once at the start of treatment and once at the end of the evaluation period. Example: Improvement in communication skills over a fixed period of time as measured by the Preschool Language Scale (PLS).

Criterion referenced and norm referenced assessment are often combined in practice. Anecdotal observations should be used to support but not replace objective and quantitative data.

TRANSITION
Individuals with ASD/PDD typically have difficulty handling even minor transitions and environmental changes in their day-to-day life. These can cause significant behavioral outbursts and regression in learning if they are not negotiated in a planned manner. Transition to a new service system leads to many changes for the individual and family including changes in service providers, location and, in most cases, service procedures. Considering the potential impact of these changes on the individual and family, certain steps need to be taken to make the transition as smooth and problem free as possible.

The following provides guidelines for accomplishing successful transition.

• Awareness of the problem and appropriate planning are key to making successful transitions for individuals with ASD/PDD. It is important to know when an individual with autism has particular difficulties with transitions and under what circumstances these occur. Some individuals will have difficulty with transitions that involve changing physical locations, some have difficulty with changes in activities, and others have difficulty with transitions among adults. Once the circumstance is understood, the plan for supportive, preventive measures can be put in place.
• Individuals with ASD/PDD should be informed several times before difficult transitions are made by explaining in terms they understand, "when" and "what" the transition will be. Major changes in daily schedules should be announced the day before, the morning of and just before the actual change. Providing a "transitional" object or picture may help some individuals. This is usually done with a small object or picture uniquely associated with the next activity or physical location where the individual is transitioning. For example, a ball typically used at recess, given to the individual upon leaving the classroom may ease the transition to the playground.
• Some individuals have difficulty transitioning from a preferred activity to a less preferred activity. Transition to the less preferred activity may be facilitated by indicating to the individual that he will have an opportunity to return to the preferred activity. Depending on the individual, return to the preferred activity may need to take place immediately or may be delayed until a later time. In addition, clearly explain the expected transition to the individual. This may be done verbally, using pictures, written words, or schedules to indicate the activities and in what order the individual will be expected to participate. As activities are completed, the individual removes them from the schedule list. This not only adds predictability to the individual’s life, but also begins building steps towards early self-management skills.
• Major transitions such as entering a new classroom with a new teacher present transitional issues for everyone involved, e.g., the individual, the family, and the teacher. The teacher should attempt to know as much about the individual as possible before the transition. This is particularly important for individuals with ASD/PDD, because many teachers have limited experience with these individuals and individuals with ASD/PDD vary widely in their educational needs. The family and the individual may also need increased supports for making this a successful transition and the planning and resources for this should be available before the transition occurs. It may be helpful to have the individual and parent visit the new classroom and teacher before classes begin. Parents should be given as much information about the new setting and its activities so that they may feel comfortable and prepare the individual more fully for the new expectations. Some individuals may need increased staffing support for a brief period at the beginning to provide instructional, prompting, and behavioral management assistance. It is important to provide such supports in a preventative and proactive manner instead of waiting until the individual has difficulty and thus develops an aversion to the new environment.
• The transition from school to work is often considered the most significant transition that an individual will face during the school years. Proactive planning, which begins by the fourteenth birthday or earlier, is the key to a positive outcome and obtaining a job. Situational assessments and vocational experiences in real settings are key to enhancing this probability. The training of parents/administrators/school staff and others to assist in this transition is critical. Full participation of the individual who is transitioning from school to work also promotes a successful outcome and minimizes anxiety about it. (Reference Community Transition)

SEXUALITY
This section describes issues relating to the sexual development of individuals with ASD/PDD. It includes an understanding of all of the areas that are affected by a person’s developing sexuality. This section is best used in conjunction with the rest of the document because sexuality is associated with the ability to communicate, to process sensory stimulation and to behave appropriately in private and social situations.

Sexuality is a natural part of life that everyone has the right to express in appropriate ways. A healthy sexual life contributes to personal dignity, interpersonal relationships and a full participation in life. Many individuals with ASD/PDD have social, communication and sensory difficulties that can impede the development of a healthy sexuality. Therefore, it is important not to overlook this area of development.

Characteristic behaviors and communication barriers displayed by individuals with ASD/PDD pose many challenges in the classroom, the community and at home. These same challenges may cause difficulty for the individual with ASD/PDD in the expression of sexuality. Often the individual’s behavior is misunderstood by others. Knowledge of the characteristics of ASD/PDD will enable caregivers to better understand these behaviors as they relate to sexuality, as well as to maintain a positive approach to learning and living. Therefore, comprehensive educational programs for individuals with ASD/PDD must address the issues of sexuality.

"It is a paradox that the individuals about whom we have the most ambivalence regarding sex education are the persons who most need it." (Sgroi, pg. 204) "I believe that sexuality education begins at birth." (Monat-Haller, pg. 41) An ongoing hierarchy of skills training should be included in any educational program for individuals with ASD/PDD. This training may begin in the early childhood years with developing an understanding of one’s body, how it works, and how it changes. As the individual develops, educational programs should teach skills for appropriate social interactions, as well as assist the individual to understand that successful relationships must be mutually fulfilling.

Individuals with ASD/PDD need to:

• Have the opportunity to make friends
• Learn skills that will assist in making friends
• Care for their own personal health and hygiene
• Understand how to interpret changes in their bodies as they develop
• Learn the social consequences of inappropriate behaviors
• Have outlets for their sexuality
• Have help in understanding these needs and in understanding the needs of others

All parties associated with the effective social-sexual development of persons with ASD/PDD must resolve all concerns and communication challenges associated with sexual subject matters. There is much we do not know about the feelings, desires and drives of individuals with ASD/PDD. It is clear, however, that many persons with ASD/PDD have a sex drive and most often express it through solo masturbation rather than through sexual experimentation with others. Families need to recognize the importance of this in order to remove the illegal atmosphere that surrounds masturbation behaviors. There is a time and a place and there needs to be some reasonable dignity and privacy associated with it.

Common Concerns Regarding Sexuality and ASD/PDD

1. Public or inappropriate displays of sexual behaviors (exposing self, public masturbation, etc.)
2. Self-injurious masturbation
3. Social contact/touching problems
4. Problems with privacy issues
5. Inability to empathize with others
6. Inability to distinguish exploitative behaviors either towards others or by others

Sexuality - Teaching Techniques
It is necessary that teaching techniques regarding sexuality be holistic, functional and concrete. Therefore, efforts to address sexuality will include a broad range of issues and objectives.

A holistic approach will consider all aspects of social preparedness for relationships and needs to include:

• An understanding of one’s own body, its function and its appropriate care
• The development and use of concrete language for body parts and functions
• Special scripts and rules to aid in the understanding of the feelings and needs of others
• Similar scripts and rules for the appropriate time and place for behaviors of sexual expression

Once the individual with ASD/PDD develops social understanding and awareness, generalizing the information from one situation to the next can be difficult, especially if the rules are unclear. Therefore, it is best to develop rules for appropriate behavior that are functional. Many times, rules are stated as expectations with defined consequences. Most people attempt to follow these rules, as they help in successful relationships and in life. As required, individuals will also modify rules and behavior to fit the situation. For example: people generally use eye contact with others as a way to indicate interest and respect. In certain situations, such as in elevators, this rules changes. In elevators, eye contact is not welcomed and can be considered threatening. Individuals with ASD/PDD will have difficulty predicting these type of expectations unless they are specifically taught about, and supported in, these confusing situations.

Temple Grandin (1995) organized situations by categorizing them into three categories: really bad (stealing, property destruction and hurting others), sins of the system (smoking, public sexuality, cursing, etc.) and illegal but not bad (speeding, double parking or jay walking). Temple described that she does not have any social intuition and she relies on pure logic. She categorizes rules according to their logical importance and not by her emotion. Her insight is h