Introduction to Relationship Development Intervention: Remediation

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Steven Gutstein Ph.D.
www.rdiconnect.com
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Types of Psycho-social Interventions

• Compensation Temporary work-around
  (First Generation)
• Substitution Permanent alternative pathway
  (Second Generation)
• Remediation Correcting core deficits
  (Third Generation?)

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What is a Remediation Program?

• Remediation is about correcting deficits
  that are creating barriers to
  attaining a quality of life
• Remediation is a developmental process,
  Involving searching for the period in
  development where the child hit a wall and was
  not able to progress further
• Remediation is a gradual, systematic process
  of building competence on a step-by-step
  basis

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The goal of remediation is providing an
opportunity for Quality of Life

• Independent living
• Full, rewarding employment
• Close friendships
• Reciprocal family relationships
• Marriage

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Providing a do-over

• Children with ASD should be afforded an
  opportunity for a do-over.
• Rather than trying to teach age-level skills
  that, due to their neurological dysfunction, were
  not mastered, causing development to stop at that
  point.
• Each child deserves a second chance to address
  areas of developmental proficiency that typical
  children achieve in their early months and years

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Are Third Generation Remediation Programs
Needed?

• Many make significant strides in speech, academic
  knowledge and social skills
• However, over 95 of the highest functioning
  individuals do not develop the means to obtain a
  Quality of Life, despite normal IQ, language and
  academic achievement

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Quality of life for adults with HFA/AS
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Margaret Farelly (2001) What Happens to ASD
Adults after College

• Dr. Farelly interviewed 14 Irish young adults
  with Aspergers Syndrome, all in their 20s, who
  had spent at least several years in college. The
  following is a summary of her findings
• 14/14 were living at home
• 1/14 had obtained a B.A.
• 1/14 had full-time paid employment
• 11/14 reported no friendships
• 10/14 reported that they did not socialize
  outside of the family
• 12/14 reported significant suicidal ideation

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IQ and language do not predict success for
people with ASDs?

• IQ scores below 70 predicted poor outcome.
  However, adults with IQs over 100 were less
  successful than those with IQs between 70 and
  100 (Howlin, 2004)
• Adults with early language delays did as well as
  those with no language impairments (Howlin, 2003)
  as long as IQ gt 70

What are the crucial factors missing in the
development of people with ASD?
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At the close of their second year, NT children
undergo a significant operating system
enhancement, allowing them to engage in rapid
broadband information processing and appraisal.
Scientists refer to this enhancement as the
development of Mindfulness
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ASD A Deficit of Mindfulness?
Individuals with ASD fail to develop
mindfulness. Mental functioning cannot be
tested by IQ measures and is not related to
academic achievement, but critical for real-world
success. Without a developed mind, we are unable
to take advantage of the potential opportunities
for mental growth, offered by engaging with
increasingly complex dynamic encounters
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Nancy Minshew M.D. Carnegie Mellon University

• The brains of people with ASD demonstrate
  significant under connectivity in their formation
  of neural patterns. This limits their ability to
  respond flexibly and in a more holistic manner to
  changes in their world.

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• As ASD brains develop, they appear to preserve
  and possibly enhance the functioning of
  individual cortical processing centers
• Specific types of problems and stimuli become
  rigidly linked to specific brain centers
• In contrast, Neurotypical brains develop greater
  collaboration and distribution of different brain
  centers
• This connectivity provides the opportunity for
  flexible, original and integrated responses to
  the environment

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Peter Mundy Ph.D.University of Miami

• People with ASD do not develop a Supervisory
  Attentional System (SAS), to continually evaluate
  degrees of subjective meaning,
• The SAS acts to guide deployment of attention,
  so we continually focus on information that is
  most meaningful at that moment
• Without this capability we cannot spontaneously
  initiate strategies, or monitor strategies to
  determine if they optimally meet our needs
• We cannot rapidly change strategies to obtain a
  better fit with problems if we find they do not

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Ami Klin Ph.D.Yale Medical School

• People with autism are capable of acquiring
  language and concepts and even a vast body of
  information.
• But, these tools have limited value because they
  are acquired outside the realm of Active Social
  Engagement.
• Without engaged learning ASD children move to a
  different pathway of development, where
  accumulating information substitutes for
  engaged knowledge and wisdom.

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Peter HobsonTavistock Institute, University of
London

• People with Autism never discover that they are
  mental beings with the capacity to function in
  their personal Mental Space in a creative
  flexible manner

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The Mind A New Operating System

• An integrative processor, allowing different
  neural centers to efficiently collaborate
• A safe laboratory and engineering facility,
  testing theories, evaluating new information,
  rehearsing responses, and planning for potential
  problems
• A powerful decision-maker, conducting rapid
  appraisal of many potential environmental
  opportunities
• An attentional supervisor, managing the division
  of attentional resources to successfully reach
  multiple goals
• A mechanism for continually monitoring and
  regulating actions based upon continuous process
  data

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Minds Manage a world full of Multiples

• Perspectives
• Interpretations
• Goals
• Future scenarios
• Deploying attention
• Micro-Macro analysis
• Tight to wide focus
• Single to multi-task
• Opportunities
• Roles

• Levels of Intimacy
• Ideas
• Memories
• Emotions
• Opinions
• Perceptual relations
• Meanings
• Levels of complexity
• Integrated vs. localized processing

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You Dont Need a Mind for

• Memorization
• Enacting social skills
• Reading for decoding and surface meaning
• Following logical arguments
• Using learned strategies concepts
• Executing procedures formulas
• Following flow charts
• Math computation
• Writing paragraphs providing accurate description
• Recounting a sequence of events
• Following rules

• Solving math word problems
• Playing most computer games
• Writing sentences with proper grammar
• Operating a computer
• Working for a desired reward
• Telling a joke
• Discriminating between different emotional
  expressions
• Being polite
• Asking questions
• Making requests
• Playing board games
• Being friendly
• Accumulating specialized knowledge
• Publishing a research paper

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Mindfulness Deficits in ASD

• Analysis
• Anticipation
• Appraisal
• Classification
• Comparison
• Generalization
• Generation

• Internalization
• Postponement
• Reflection
• Representation
• Substitution
• Synthesis

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Analysis

• Many-to-one relationships
• One-to-many relationships
• Perceptual regularities
• Recurring patterns
• Spatial relationships
• Subjectivity

• Centrality
• Certainty
• Continuity
• Figure-ground
• Gaze
• Incongruity

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Analysis

• Distinguishes between attributes critical for
  defining a concept and those that are commonly
  associated, but not essential
• Distinguishes between peripheral variations that
  enhance activities and variations that disrupt
  activity frameworks
• Understands that a more complex version of a
  prior role is still a form of the original role
• Realizes that the same tool can be used
  appropriately in multiple ways
• Realizes that people's role actions will differ
  when observed in different settings
• Recognizes that the same actions can produce
  different results when taken during different
  activities or settings

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Analysis of Permanence
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Anticipation (Preparedness)

• Expectancies
• Planning
• Preparing
• Previewing
• Rehearsing

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Anticipation

• Prepares contingency plans to be used if original
  plans do not work out as expected
• Previews representations of future goal
  attainment
• Expects that help is not always available when
  needed
• Recognizes that original plans may not work as
  expected
• Expects that invitations made to partners for
  interaction will not always be accepted
• Does not assume that feelings will always be
  reciprocated

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Appraisal

• Environments present many potential ways we can
  organize, relate and prioritize information.
  Appraisal is the way we analyze a situation,
  setting, or interaction and determine what has
  most personal meaning at that time.
• The appraisal process provides ongoing evaluation
  of environmental demands, constraints and
  resources in relation to personal goals. Based on
  this moment-to-moment assessment, we allocate and
  re-prioritize our attentional resources.
• Flexible appraisal affords enormous evolutionary
  advantage. Without appraisal we are limited to
  responding to our environment in a rigid,
  inflexible manner

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Figure-Ground Appraisal
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Appraisal

• Appraising safety
• Appraising standards
• Appraising sufficiency
• Appraising task requirements
• Appraising time needs
• Appraising trust
• Appraising uncertainty
• Appraising value

• Appraising mistakes
• Appraising need for help
• Appraising obstacles
• Appraising optimal pace
• Appraising quality of work
• Appraising readiness
• Appraising resource availability

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Appraisal

• Determines acceptable standards for performance
  based on a good-enough analysis of the task
• Knows that many problems have no right and wrong
  answers, only those that constitute a "best-fit"
• Evaluates the usefulness of solutions given
  specific contextual information at hand
• Distinguishes between important and unimportant
  changes in daily routines
• Appraises when and where to consider rules as
  absolute in enforcement and when to consider them
  as relative
• Recognizes that interruptions are not necessarily
  wrong during conversations depending on the
  context

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Classification

• Assimilating
• Conditional classification
• Cross classification
• Degree of fit with class
• Hierarchical Classification
• Membership Determination
• Organizational Strategies
• Prioritizing
• Relative Classification
• Temporary Classification

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Classification

• Classifies a single object as belonging to
  multiple categories
• Distinguishes between different degrees of
  certainty
• Employs the concept of closer and farther in a
  relative manner dependent on what has come before
• Classifies episodic memories into categories
  based upon similar subjective evaluations
• Distinguishes between true inner feelings and
  superficial expressions
• Understands that one must communicate one's needs
  in order for someone to know about them and
  provide help

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Internalization

• Self Analysis
• Self Correcting
• Self Evaluating
• Self Instruction
• Self Monitoring
• Self Motivating
• Self Narrating
• Self Soothing

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Reflection

• Attributing
• Evaluating
• Narrating
• Recounting
• Reflecting
• Reminiscing
• Self-Evaluating
• Troubleshooting

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Bandwidth

• Bandwidth refers to the transmission capacity of
  a communication pathway
• From a neurological perspective, broad bandwidth
  processing refers to our ability to integrate
  many different brain processing centers working
  collaboratively to determine complex levels of
  meaning.
• The mind as a brain structure develops as a
  response to increasing need to integrate the
  simultaneous integration of multiple channels of
  information into more efficient but complex
  schemas, while filtering un-related,
  non-critical information in an efficient manner
• In ASD remediation, bandwidth refers to the
  extent the person can integrate multiple channels
  of information to determine meaning and respond
  flexibly

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Communication Bandwidth

• Successful human communication requires
  processing information along a wide bandwidth.
  We interpret the meaning of any communication by
  many factors presented simultaneously
• Bandwidth factors include prosody (the changes in
  tone, emphasis, inflection and pacing that lies
  behind your words), facial expression,
  gestures, posture, physical space, context and
  prior relationship with the communication partner
  
• Neurotypical children go through a gradual
  bandwidth expansion beginning at birth as they
  gradually broaden the bandwidth elements that
  they can integrate within a single communication
  episode.
• Children with ASD develop communication on a very
  narrow bandwidth
• Even those without significant language delays
  develop speech, a very narrow band of
  information instead of the non-verbal channels
  of communication
• Unfortunately most autism interventions reinforce
  narrow bandwidth processing by focusing only on
  the non-prosodic speech channel

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Declarative Communication

• Declarative communication is the representation
  what the mind produces
• It is the product of the highest level of mental
  functioning we can share with specific partners
  in a meaningful way
• Declarative communication offers the opportunity
  to share subjective experiences feelings,
  intended actions, memories, predictions, plans,
  ideas, perspectives, thoughts, and creative
  productions
• We initiate declarative communication to invite
  anothers insights and perspective, and integrate
  them with what we already know.
• Responses to declarative communication cannot be
  taught as a one-to-one relationship with a
  stimulus,
• The person who initiates a declarative cannot be
  invested in obtaining a specific response
• Declarative communication is always broad band.
  The non- verbal communication that goes along
  with declarative communication is information
  rich. 
• In contrast to typical children, those with ASD
  initiate almost no declarative communication

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Communication Tools

• Prosody Prosody is the non-speech aspect of
  vocal communication, that significantly alters
  the meaning of speech and provides information
  about how to interpret any message. Prosodic
  elements include stressing a syllable or word,
  intonation, volume, pauses and selective
  alterations in rapidity of speech. Prosodic
  elements of communication emerge prior to 9
  months of age in typical infants. They are
  lacking or severely impaired in ASD individuals.
• Physical enactment Gesture, posture use of
  physical space
• Facial expressiveness
• Language personalization (generalized vs.
  formulated for the specific listener)

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Communicative Context

• Having to do with the factors that influence the
  meaning of any piece of information. Information
  itself has no particular meaning unless we
  subjective assign meaning to it. The appraisal
  process is dependent on having different ways of
  evaluating context.

• Information that has preceded and is anticipated
• Participants role relationships
• Awareness of the communicators intent
• The degree of familiarity of participants
• Mood carried over from prior episodes
• Participants perception of self efficacy within
  the setting
• Setting-associated rules and expectations

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Communication Repair

• The concept of repair involves the child
  learning at a young age that communication and
  interaction in dynamic systems will inevitably
  break down despite our best efforts at
  regulation.
• Infants learn to monitor breakdowns and make
  repair attempts as early as 18 months of age.
• ASD individuals do not appear to understand that
  communication must be monitored for potential
  breakdowns. Therefore they do not develop repair
  skills

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Self-Regulating Communication

• A critical feature of declarative communication
  is that it is a pre-cursor to developing
  productive self-regulating communication.
• Beginning shortly after the age of two,
  declarative forms of language divide into two
  tracks
• one track continues to develop more sophisticated
  ways to share aspects of ourselves with others.
  The second declarative track emerges as a tool
  for engaging with ourselves. 
• During the course of their third year,
  Neurotypical children learn to narrate their own
  actions, internally plan, reflect on what they
  are doing, pace their actions and regulate their
  states of distress
• Without this self dialogue, we are left with
  choosing between other people controlling us, or
  becoming constant victims of our unmanageable
  impulses.
• ASD children do not appear to use self-regulating
  communication.

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Communication Competence

• Build communication as a wide bandwidth
  phenomenon
• Slow down your pace of talk and use fewer words
  to increase mental processing. Make sure thought
  precedes speech
• Emphasize quality of communication over quantity
• Model use of language for reflection,
  Mindfulness, experience-sharing, co-regulation
  and self-regulation (self talk)
• Teach the inevitability of communication
  breakdowns and need for ongoing monitoring,
  maintenance and repairs

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Curriculum Guidelines

• Strike a dynamic balance between acquisition and
  mental engagement. Accumulating knowledge should
  not be rewarded for its own sake
• Reading should be taught as an active,
  extractive, appraising, translating and
  integrating process
• Writing should be taught as the expression of
  meaningful knowledge or thought provoking stimuli
  that can effectively be used by the intended
  audience (including oneself)
• Mathematics should be taught as the use of
  computation, estimation, measurement, and
  quantitative analysis for meaningful real-life
  problem solving

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• Science should be taught as a process of learning
  to think like a scientist
• Hypothesizing, experimenting, discovering,
  classifying, building theories,
• learning about dynamic interrelationships,
• looking at the same object or event at all
  levels from micro to macro,
• understanding the developmental process,
• distinguishing between knowledge, theory and
  speculation

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• History should emphasize
• the relationship of past, present and future,
• how small events have resulted in huge impacts,
• how single individuals affect the world,
• how progress is a relative term,
• how we can capture the emotional impact of past
  events,
• how we learn and sometimes dont learn from past
  mistakes,
• how we are all connected to our past,
• how history is subjective
• How history consists of every moment before the
  present

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• Behavioral management plans are geared towards
  self regulation
• Student learn to monitor and reference their
  environment and teacher
• Teachers maintain regularity through routines,
  but emphasize continual variation
• Students learn to track and record their own
  behavior

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Beginning Active Reading Objectives

• The student demonstrates that he/she can
  meaningfully read narrate and translate what
  he/she reads into his/her own meaning system.
• The student consistently reads in small,
  meaningful chunks, stopping after each chunk to
  make sure he or she has full comprehension before
  proceeding on.
• The student of capably understanding task
  instructions, directions and questions and using
  them accurately to solve problems and complete
  tasks.
• The students reading is based on active
  translation of information. The student can tell
  you what he or she reads in his/her own words
  (the student can tell you accurately what he
  needs to do in his own language).

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School Activities for Mental Engagement

• Thoughtful reading (e.g. Pace determined by level
  of comprehension asking yourself questions as
  you read).
• Learning how to most efficiently find needed
  information.
• Writing for different purposes (e.g. Note taking,
  calligraphy, influencing others etc.) and for
  different audiences
• Good enough best fit problem solving (e.g.
  Planning time, effort and judging completeness
  of projects and tasks).
• How optimal precision and accuracy varies for
  different problems

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• Learning to make more accurate predictions
• Preparing for multiple potential future outcomes
• Learning multiple relative categorical
  membership
• Determining multiple correct solutions to the
  same problem and determining when each might be
  more useful.
• Learning productive what-if speculative
  thinking in history.
• Developing and testing hypotheses in science.
• Solving problems by improvising with whatever
  tools are at hand

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• Learning how to distinguish critical events
  during episodes
• Learning to maintain regularly reference a
  journal containing important personal episodic
  memories
• Learning to generalize strategies to more than
  one task and maintain a useful, indexed strategy
  book
• Learning to productively reflect on prior
  mistakes and setbacks through troubleshooting.