The Autism Society Event and Education Recordings Archive

The Center for Autism and Related Disorders (CARD) is a large-scale service delivery agency that provides treatment, training, and consultative services to hundreds of individuals with autism around the world. CARD’s mission is to extend top-quality behavioral treatment to the maximum number of individuals with autism possible. Neither quality nor quantity can be compromised in this mission. The purpose of this presentation is to highlight the CARD model of service delivery. Applied Behavior Analysis is a methodology based on the principles of Operant Conditioning Theory. Operant Conditioning Theory states that Human Behavior is affected by its' antecedents and consequences. Applied Behavior Analysis (ABA) is the application of the principles of behavior analysis to solving problems of social significance. As behaviorists, we separate the characteristic symptoms of Autism into deficits and excesses. Deficits include language, play, social skills, meta and social cognitive skills, and executive functioning skills. Excesses include self-stimulatory behaviors or stereotypies and maladaptive behaviors such as tantrums, aggression and non-compliance. In any given child, once the specific deficits and excesses being exhibited are identified, a comprehensive behavioral program aims to teach appropriate replacement skills and manage behaviors concurrently. The former is termed Skill Repertoire Building and the latter, Behavior Management. These two components go hand-in-hand in developing an appropriate behavioral program. The CARD treatment program was developed in 1990 and continues to be modified and further improved each year. The model is based on the theories of Applied Behavior Analysis and is intended for children from birth to adulthood. The model is intensive and achieves highest success when administered at an intensity of 40 hours per week. The model establishes a distinct shift from home or center-based 1:1 structured instruction to natural environment instruction in the community. The CARD ABA program can be examined according to its targets and contents in each year of intervention. A typical four year program begins with 30-40 hours of intervention in the first year when the child is entering at 24-36 months of age. During this period, the analyst's objective is to establish a relationship with the child, to identify his or her reinforcers and establishing operations and to determine ways in which to use these to motivate the child to learn. Replacement behaviors are reinforced with the intention of extinguishing maladaptive behaviors and the child is taught the basic functions of language so as to increase and maintain appropriate behaviors. Echoic training, alongside non-verbal imitation aids the child in paying attention to the environment and learning to match his or her repertoire of behaviors to those of others while mand and tact training teaches the child functional ways to use language to request and label everyday items. In addition, the first year program includes an introduction to toy and pretend play activities as well as basic self-help skills such as feeding and toileting. In the second year, the focus of the program diversifies to include skills necessary for preschool. The child is now 36-48 months of age and will likely benefit from 5-10 hours of attendance in a preschool setting where he or she is shadowed by an analyst equipped to assist in generalization of mastered skills and enhancement of social skills. The objectives for the second year include expansion of receptive language skills, development of expressive skills to pure operant level (unprompted mands and tacts) and expansion upon the intraverbal skills of language. In addition, early emotion recognition and inferences are taught as these skills are essential to the development of later social and socio-cognitive benchmarks. As the child enters the 5th year of life, interaction with peers becomes essential and the emphasis of the program shifts once again. In this year, the child is infused into school and half of the ABA program takes place in the normal classroom setting where a shadow prompts the child to interact, attend and learn by observing the behavior of others. There is an emphasis on pragmatic language as conversational skills take priority in the child's life and abstract concepts such as Theory of Mind are introduced. As the child is nearing completion of the ABA program, executive functioning skills are assessed and self-monitoring, planning and problem solving techniques are identified and taught. In the final year of treatment, at the age of 5-6 years the child will often have successfully integrated into school and the program begins to fade out as independent skills are acquired. In this year, the emphasis of the program is commonly identified on an individual basis and is fully dependent upon the remaining deficits exhibited by the child. Typically the majority of work done in the last year focuses on advanced social language (e.g., detecting sarcasm), understanding intentions and deception and continued self-monitoring. While most children develop academic skills well in advance of their peers, if the child requires continued assistance in academic areas, these are targeted in the final year. ABA programs base their foundation on behavioral techniques and principles. These principles lead to the development of methodologies such as the discrete trial, errorless training and incidental teaching modalities. These modalities identify the “how to” of instruction. An equally relevant question becomes: “What shall I teach?” The CARD curriculum was developed on the premise that all skills can be taught. The curriculum is based on normal development with consideration of specific skills that only require step by step instruction for children with autism. The curriculum consists of target behaviors that have been sub-divided into single operant steps across a wide array of skill areas. The curriculum areas include Language, Play, Adaptive, Motor, Cognition, Social skills, Executive Function, and School Skills. Acquiring Language is more than learning the meaning of words. One cannot assume that a child will use language when he acquires the meaning of words. As such, the CARD curriculum follows Skinner's application of language and teaches the 6 basic functions of language (Skinner, 1957). These include imitation, requesting, matching, labeling, receptive language and conversation. Each concept is taught according to these functions of language so that maintenance occurs as a result of functionality and generalization occurs more naturally. In addition, the topography of language is attended to and instructional emphasis is placed on phonologic, morphological, semantic, syntactical and pragmatic usage of language concepts as well. The overall goals in teaching language are to ensure spontaneity of use, to emphasize language that is functional in everyday situations and to ensure generalization. The features of a comprehensive play skills curriculum include it's sequential format such that programs can be used individually, concurrently or cumulatively to teach appropriate play. In addition the CARD play curriculum is modeled after the development of play skills in typically developing children and it breaks down each type of play skill into its own systematic and comprehensive program of instruction. The target areas of play include beginning play, functional pretend play, symbolic play, constructive play, imaginary play, sociodramatic play, practice play, games with rules and independent play tracking. Since ABA programs for children with Autism begin very early in the child's life, self-help skills as early as feeding, drinking and eating must be taught. In addition, other self-help skills that are necessary in daily living are included in CARD's self-help curriculum and these include toileting, dressing, bathing, grooming and other household and community skills. Early assessments help identify the need for intervention in fine or gross motor skills. Intervention is modified depending on the child's deficits to include necessary skills. As children with autism tend to lack the early pointing skills, this skill identifies the first skill in fine motor intervention while more advanced steps include manuscript writing and finger manipulations. Moreover, in cooperation with occupational therapists and physical therapists, gross motor skills as basic as standing and walking are taught to younger children while more advanced skills of riding a bicycle, or walking on a balance beam are practiced with school aged children. Cognition or the ability to “know” can be divided into two areas; meta cognition or knowledge we have about our own processes, and social cognition, the knowledge we derive about the mental processes of others. More specifically, Social Cognition or Theory of Mind is the ability to infer the mental states of other people's emotions, thoughts, knowledge, desires, beliefs and intentions. Typical social cognitive development includes social referencing at 9 months, pretense at 15 months, understanding of desire and intention at 18 months, understanding the crucial difference between knowing and thinking at 3 years of age, understanding lies and deception at 4 years of age and comprehension of intentionality at 5 years of age. The CARD social cognition curriculum addresses each of these topic areas by teaching generalized behavioral skills relevant to each. The CARD Social Skills curriculum is a collection of programs, procedures and activities for teaching social norms and behavior. It is designed to be used in the natural settings such as the child's home, school or community. Skill areas that are taught include social play, following social rules and community appropriate social behavior. Specific skills are also taught in target areas such as choral activities, sharing and turn taking, responding to social cues, group discussions, levels of friendship, positive self-statements, apologizing, cooperation and negation, safety awareness, winning, losing, and dealing with conflict. The executive functions are controlled by the pre-frontal cortex of the brain. These functions allow us to exhibit goal-directed behaviors. Goal direction involves visualization of a situation, identification of desired objectives, determination of a plan to meet the objectives, monitoring one's own progress to the goal and inhibition of distractions. Children with autism and particularly, children with Asperger's disorder exhibit delays in many of the areas noted above. As such, the CARD executive function curriculum focuses on teaching flexibility, working memory, attention, self-monitoring and inhibition with ultimate goals of enhancing problem solving and planning skills. By approaching these concepts as generalized learned behaviors, we are able to identify exactly which skills are needed and how to teach them from a behavioral perspective. As the child with autism approaches typical functioning, one of the critical elements to consider is instruction of school skills. While some children excel in these areas, others have particular difficulty with concepts in mathematics, reading or writing. A large number of programs have been designed to address these deficits and CARD's school skills curriculum allows individual selection of programs that help teach the child techniques and core concepts that enhance the child's abilities to master academic topics. The CARD curriculum is a collection of skills listed in simple operant format, intended for instruction through the use of behavior analytic procedures for children with autism. Many providers of ABA programs will use similar techniques of instruction. However, the content of instruction that has been noted here is unique to CARD. It had been our experience that children with autism exhibit a wide array of skills and deficits. As such, the curriculum that we have developed is intended to allow the analyst to choose skills necessary for instruction for each child. It is not intended to be a cook book that is followed in it's entirety but rather a pool of programs to choose from based on formal assessment of a child's skills and deficits and in accordance with the sequence of typical development. The CARD II is a program designed for students from 8 to 21 years old with a current or previous diagnosis on the autism spectrum. The program assists students whose families require support managing problem behaviors as well as teaching basic communication skills and adaptive skills. It also assists students who are mildly affected and may need assistance only to acquire more complex social skills and apply them with their peers in their natural environments. The CARD II curriculum is based upon a specific skill hierarchy including, treating challenging behaviors, functional communication, adaptive skills, vocational skills, language concepts, grade level academics, and social language and skills. CARD's Specialized Outpatient Services (SOS) provides a suite of services targeted at making meaningful and rapid changes in high-priority behaviors. CARD SOS provides assessment and treatment of pediatric feeding disorders, assessment and treatment of severe behavior disorders, and facilitation of compliance with medical procedures. CARD SOS services are provided on a home-based, school-based, and outpatient basis, for as long as necessary depending on the unique needs of each individual client. Services include direct intervention, caregiver and teacher training, and planning for generalization and maintenance. CARD SOS serves individuals with and without developmental disabilities.

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