Maximizing Global Access to Effective Treatment: Center for Autism and Related Disorders (CARD), CARD eLearning ™ and Skills ™

Type of measure

Instrument

Reference

Diagnostic

Autism Diagnostic Interview, Revised (ADI-R)

Rutter et al. 2003

Autism Diagnostic Observation Schedule (ADOS)

Lord et al. 1999

C.A.R.D Autism Symptoms Questionnaire (CARD ASQ)

Childhood Autism Rating Scale (CARS)

Schopler et al. 1988

Checklist for Autism in Toddlers (CHAT)

Baron-Cohen et al. 2000

Gilliam Asperger’s Disorder Scale (GADS)

Gilliam 2001

Gilliam Autism Rating Scale—Second Edition (GARS-II)

Gilliam 2006

Pervasive Developmental Disorders Behavior Inventory (PDDBI)

Cohen and Sudhalter 1999

Intelligence

Differential Abilities Scales (DAS)

Elliott 1990

Leiter International Performance Scale—Revised (Leiter-R)

Roid and Miller 1997

Merrill-Palmer-Revised Scales of Development (M-P-R)

Roid and Sampers 2004

Wechsler Intelligence Scale for Children—Fourth Edition (WISC-IV)

Wechsler et al. 2004

Wechsler Preschool and Primary Scale of Intelligence—Third Edition (WPPSI-III)

Wechsler 2002

Developmental

Bayley Scales of Infant and Toddler Development—Third Edition (Bayley-III)

Bayley 2006

Brigance Diagnostic Inventory of Early Development—Second Edition (IED-II)

Brigance 2004

The Developmental Profile II (DP-II)

Alpern et al. 1980

Adaptive behavior

Vineland Adaptive Behavior Scales—Second Edition (Vineland-II)

Sparrow et al. 2005

Motor

Test of Gross Motor Development—Second Edition (TGMD-2)

Ulrich 2000

Visual-motor

Beery-Buktenica Developmental Test of Visual-Motor Integration—Fifth Edition (Beery VMI-5)

Beery and Beery 2004

Psychoeducational

Psychoeducational Profile—Third Edition (PEP-3)

Schopler et al. 2005

Speech and language

Clinical Evaluation of Language Fundamentals—Fourth Edition (CELF-4)

Semel et al. 2003

Clinical Evaluation of Language Fundamentals—Preschool (CELF-P)

Wiig et al. 1992

Goldman–Fristoe–Woodcock—Test of Auditory Discrimination

Goldman et al. 1970

Peabody Picture Vocabulary Test—Third Edition (PPVT-III)

Dunn and Dunn 1997

Preschool Language Scale—Fourth Edition (PLS-4)

Zimmerman et al. 2002

Rossetti Infant—Toddler Language Scale

Rossetti 1990

Test of Language Development: Intermediate—Third Edition (TOLD-I:3)

Hammill and Newcomer 1997

Test of Language Development: Primary—Fourth Edition (TOLD-P:4)

Newcomer and Hammill 2008

Test of Problem Solving—Third edition (TOPS-3)

Bowers et al. 2005

Pragmatic language

Test of Pragmatic Language—Second Edition (TOPL-2)

Phelps-Terasaki and Phelps-Gunn 2007

Social skills and play

Social Behavior Assessment Inventory (SBAI)

Stephens and Arnold 1992

Social Skills Improvement System Rating Scales (SSIS)

Gresham and Elliott 2008

Social Responsiveness Scale (SRS)

Constantino and Gruber 2005

Symbolic Play Scale

Westby 1991

Executive functioning/neuropsychology

Behavior Rating Inventory of Executive Function—Preschool Version (BRIEF-P)

Gioia et al. 2003

Behavior Rating Inventory of Executive Function (BRIEF)

Gioia et al. 2000

Children’s Color Trails Test (CCTT)

Llorente et al. 2003

The Auditory Sequential Memory Test

Wepman and Morency 1973

Test of Auditory Discrimination (ADT)

Wepman and Reynolds 1987

The Stroop Color and Word Test

Golden 1978

Wisconsin Card Sorting Test

Grant et al. 1993

Treatment evaluation

Autism Treatment Evaluation Checklist (ATEC)

Rimland and Edelson 1999

Achievement

Johnson III Tests of Achievement

Woodcock et al. 2001

Other

Aberrant Behavior Checklist (ABC)

Aman and Singh 1986

Behavior Assessment System for Children (BASC-2)

Reynolds and Kamphaus 2004

Clinical Global Impression (CGI)

Guy and Bonato 1970

Parenting Stress Index (PSI)

Abidin 1995

CARD has developed eight curricula to address all eight of the developmental areas of functioning (social, motor, language, adaptive, play, executive functions, cognition, and academic skills). The Social curriculum emphasizes teaching the child skills that will maximize successful social functioning. The child learns social rules, social interaction and relationship-building skills, and how to use social language successfully. The Motor curriculum focuses on teaching fine motor (e.g., hand skills such as twisting and finger skills such as the pincer grasp), gross motor (e.g., jumping, catching), and visual motor skills (e.g., tracking, scanning). The Language curriculum focuses on teaching the child to understand language by teaching concepts such as matching and receptive identification and to use language functionally by teaching concepts such as using language to request, label, and converse. The Adaptive curriculum teaches personal (e.g., teeth brushing, toileting), domestic (e.g., making the bed), safety (e.g., stranger safety, using safety equipment), and community skills (e.g., restaurant skills). The play curriculum starts by teaching the child appropriate toy play skills (e.g., sensorimotor and manipulative play, constructive play, pretend play) and then progresses to teaching the child to use his or her play skills socially in play with peers. The Executive Functions curriculum teaches the child skills necessary for goal-directed behavior. This includes teaching skills related to inhibition, attention, flexibility, memory, problem solving, planning, and self-management. The Cognition curriculum focuses on teaching the child to understand and respond to the mental states of others, thereby allowing the child to predict others’ behavior and modify his or her interactions with others in order to make the interactions more effective (perspective taking or Theory of Mind). Some example topics covered in the Cognition curriculum include: desires, emotions, senses, physical states, thinking, preferences, knowing, beliefs, deception, sarcasm, and intention. Finally, the Academic curriculum emphasizes skills related to math and language arts. In total, the CARD curricula are made up of almost 4,000 individual activities that teach skills comprised of over 40,000 individual instructional targets.

Treatment Procedures are Rooted in ABA

EIBI programs utilize scientifically validated intervention techniques based on the principles of behavior analysis (Love et al. 2009). CARD programs incorporate a variety of behavior analytic procedures shown to be effective with children with autism and common to all good ABA programs (Tarbox and Granpeesheh, 2011). Procedures include prompting and fading, discrimination training, preference assessment, shaping, chaining, and explicit programming for maintenance and generalization. Procedures are always selected and tailored according to each child’s individual needs. A full review of the different behavioral procedures used at CARD is beyond the scope of this chapter, but we provide an outline describing the most commonly used procedures for those new to ABA techniques. The most common teaching techniques used at CARD are discrete trial teaching (DTT), natural environment training (NET), and fluency-based instruction (FBI). DTT, a scientifically supported teaching procedure for children with autism (Tarbox and Granpeesheh, 2011), is a therapist-led procedure delivered in a 1:1 setting and is frequently used to teach discrimination skills (e.g., how to vocally label objects and how to receptively identify objects). DTT involves breaking down complex skills into basic units of behavior that are taught through a series of discrete teaching trials. In this way, multiple learning opportunities are presented to the child within a short period of time. Blocks of discrete trials are continuously presented until the child reaches a predetermined mastery criterion (e.g., 80–100 % correct over a predetermined number of trial blocks).

The beginning of each discrete trial is signaled by an instruction. The child then has the opportunity to respond (usually within 3–5 s). The therapist uses prompts to guide the child to the correct response, fading the prompts as the child begins to acquire the target skill. Immediately following the child’s response, a consequence is delivered, signaling the end of the trial and providing feedback to the child regarding his/her response (i.e., whether he/she was correct). A desired response typically results in deliverance of a favored item, activity, and/or praise. Inappropriate responses, on the other hand, are followed by vocal feedback (e.g., “no” or “try again”) and are usually followed by an error correction procedure.

Unlike DTT, NET procedures are considered child led and involve therapists capturing and contriving teaching opportunities within the child’s natural environment (e.g., during play activities, mealtimes, or routines such as getting dressed). Further, the natural consequence of the behavior acts as the reinforcer where possible (Cowan and Allen 2007; Delprato 2001). Therapists use prompting and fading as necessary to guide the child to demonstrate the target skill successfully. An advantage of NET is that skill generalization is encouraged, thus decreasing the need for additional generalization programming (e.g., Cowan and Allen 2007; Delprato 2001). NET is often used to teach language skills (e.g., Charlop-Christy and Carpenter 2000; Charlop-Christy and LeBlanc 1999; Koegel et al. 1998), play skills (Stahmer 1995; Stahmer et al. 2003; Thorpe et al. 1995), and social skills (e.g., Harper et al. 2008; Kaiser et al. 2000; Kohler et al. 2001; Krantz and McClannahan 1998).

FBI involves the use of a free operant procedure which essentially means that the child is given the opportunity to respond freely and as quickly as possible , undertaking a task for a period of time (usually anywhere from 10 seconds to 1 minute). This procedure is employed to increase both the child’s accuracy and speed in an attempt to allow the child to become fluent at a skill. Fluent performance is defined as the rate of responding necessary for competent performance (Binder 1996). FBI is commonly used to teach math and reading skills but can also be relevant to other skills (e.g., tying shoes, buttoning, speaking). FBI is often implemented once the child is performing accurately during DTT or NET sessions with the goal of now getting the child to perform the skill automatically and without hesitation (fluently).

Younger CARD clients aged between 1–3 years typically have programs containing more social and play- based targets, taught mostly through NET and an errorless learning approach, which involves providing the child with guidance to ensure that he or she is successful during every teaching opportunity, fading the level of guidance provided as the child becomes proficient at the target skill. CARD programs for children aged 3–5 years typically involve a broader range of skill targets taught via a combination of DTT and NET. FBI techniques are generally used once the child has demonstrated accuracy with a DTT or NET procedure in an effort to promote accuracy combined with speed (fluency).

In addition to teaching new skills, a goal of all CARD programs is the reduction of challenging behaviors, such as stereotypy, self-injury, aggression, and noncompliance, and the replacement of these with adaptive behaviors. This process begins with an assessment to identify the function of the behavior (i.e., the conditions under which the behavior occurs). Supervisors are then able to design an individualized behavior intervention plan based on the results of the functional assessment (for a discussion of function-based interventions, readers should refer to Filter and Horner 2009 and Ingram et al. 2005). CARD behavior intervention plans involve not only strategies for reducing challenging behavior when they occur but, also, strategies for preventing the behavior from occurring, as well as strategies for teaching appropriate replacement behaviors. CARD supervisors train both therapists and family members to implement behavior management protocols consistently and closely monitor the behavior to ensure the plan is effective.

Once skills have been taught and challenging behavior has been reduced, the final step of the CARD treatment process is to ensure that maintenance and generalization are achieved (i.e., taught skills continue to be used over time and occur in the natural environment across people and in different settings, etc.). Generalization and maintenance rarely happen on their own; thus CARD supervisors design an individualized maintenance and generalization plan for each child and continuously monitor the plan to ensure that the strategies employed are successful (see Brown and Odom 1994; Ghezzi and Bishop 2008; Stokes and Baer 1977; and Stokes and Osnes 1989 for in-depth reviews of strategies for generalization and maintenance).

Ultimate Goal is Integration into a Classroom Setting

The ultimate goal of EIBI programs is most often the successful integration of the child into the classroom (Howard et al. 2005; Sallows and Graupner 2005). At CARD, treatment is typically conducted in the child’s home initially and then generalized into classroom and community settings as appropriate for the child’s age. The first year of CARD treatment typically consists of intensive work on language and behavior management. The second year involves a progression into social skills, developing into a focus on more abstract cognitive and executive functioning skills in the third year. The fourth and final year emphasizes a gradual fade out of services. However, children with less severe diagnoses of PDD-NOS or Asperger’s Syndrome may require a focus on social, cognitive and executive functioning skills, delivered through a more cognitive behavioral format. Ultimately, the progression of a child’s treatment program will depend on his or her initial profile.

Other Features of CARD Treatment Programs

In addition to the above core EIBI features, all CARD programs incorporate a holistic philosophy emphasizing a need to treat the whole child, including acknowledging health and sensory needs. We believe that optimal learning occurs with stable health, adequate sleep and functional regulation of sensory input. The assessment process therefore includes assessing sensory dysregulation in the visual, auditory, tactile and proprioceptive modalities and conducting full medical and health evaluations wherever possible in order to identify any underlying or co-morbid medical, sensory or dietary issues that might de-stabilize the child’s health, sleep and ability to attend. CARD supervisors are then able to make adjustments to treatment procedures and materials wherever appropriate, so as to maximize treatment outcome.

Finally, at CARD we believe that every child has personal dignity, individuality, and self-determination; thus CARD treatment programs aim to continuously encourage the expression of personal beliefs, feelings, interests, and preferences.

Format of Service Delivery

Home-Based

For those children who reside within 30 miles of a CARD office, CARD offers home-based services. This format of service delivery involves CARD therapists conducting 1:1 therapy sessions in the child’s home at regularly scheduled times. The majority of therapy is conducted in a designated “therapy room” with skills being targeted throughout the child’s home where more appropriate. Home-based sessions provide excellent teaching opportunities by allowing increased access to the child’s home environment, including his/her toys, daily living materials, and family routines.

Workshop-Based

For those families who are located outside the 30-mile radius or reside in a state or country without a CARD office, CARD offers remote clinical services. Remote clinical services begin with an initial 2–3 day workshop conducted in the child’s home. The aim of this workshop is to assist the family in setting up a home-based CARD ABA treatment program with periodic consultation with a CARD clinical supervisor. The supervisor spends the first day of the initial workshop training family members and therapists in behavior principles, skill acquisition, and maintenance, behavior management techniques, and data collection. The next 1–2 days are spent teaching parents and therapists how to implement the child’s CARD ABA treatment program successfully. Following the initial workshop, the supervisor continues to provide periodic consultation through face-to-face visits, phone/video conferences, and correspondence via fax, e-mail, or mail.

Outcome of the CARD Treatment Model

CARD’s research and development department has published over 60 research articles in peer-reviewed scientific journals and has contributed over 25 chapters to edited scientific texts. CARD’s scientific work spans several programs of research, including (a) assessment and treatment of challenging behavior, (b) procedures for teaching basic language and verbal behavior, (c) social skills interventions, (d) teaching independent living skills, (e) treatment of feeding disorders, (f) factors affecting outcome of EIBI, (g) teaching higher-order cognition and executive function skills, (h) procedural and methodological innovations, (i) the role of technology in autism treatment, and (j) recovery from autism. Below, we briefly describe publications from each of these programs of research.

CARD research on challenging behavior has innovated nonintrusive treatment procedures for a variety of behaviors, such as rumination (Rhine and Tarbox 2009), bruxism (Barnoy et al. 2009), and domestic pet mistreatment (Bergstrom et al. 2011). CARD’s research on basic language and verbal operants addresses a variety of topics including procedures for increasing the complexity of verbal imitation (Tarbox et al. 2009). CARD’s research on social skills addresses areas of complex social cognition and understanding, including teaching foundational perspective-taking skills (Gould et al. 2011). CARD research on independent living skills endeavors to produce new information on how children with autism can be taught to implement useful life skills independently, such as home safety skills (Summers et al. 2011) and pill-swallowing skills (Yoo et al. 2008). CARD’s research on feeding disorders focuses on the application of nonintrusive treatments in real-life environments, such as parent-implemented home-based interventions for food refusal (Tarbox et al. 2010a). Research on the outcome of EIBI at CARD is oriented toward identifying how a multitude of variables impinges on the general outcome of EIBI, such as age and treatment intensity (Granpeesheh et al. 2009a). CARD’s research on higher-order skills is focused on developing and evaluating behavioral teaching procedures for helping children with autism improve in areas such as executive functioning, including working memory (Baltruschat et al. 2011). CARD’s research on procedural and methodological innovations investigates topics that hold promise for streamlining the treatment process and/or enhancing its efficiency, such as evaluating expedited data collection procedures (Najdowski et al. 2009). CARD researchers also maintain an active interest in the role of technology in autism treatment, including its potential for helping to aid in dissemination. CARD’s research on technology includes studies on eLearning methods for staff training (Granpeesheh et al. 2010), electronic data collection during discrete trial training (Tarbox et al. 2010b), and validation of web-based curriculum assessments (Dixon et al. 2011).

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