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How to Serve Them Through Emerging Best Practices
Trainer: Jennifer Hines M.Ed., BCBA, LBA
Neurodevelopmental Disorders Program Specialist
2019
Neurodevelopmental Disorders 201
Board Certified Behavior Analyst
Ground Rules
Give yourself permission to fully engage and learn
There are no dumb questions
Respect peers and take distracting calls, emails etc. outside
Have fun!
Welcome!
Who is Your Trainer?
Bachelors in Social Work, Masters in Special Education (cognate in Autism & Emotional Disturbance), Board Certified and Licensed Behavior Analyst
Ph.D. Student in Organizational Leadership
26 years in the field of developmental disorders: social worker, special education teacher (mostly Autism, all grades), district behavior specialist, assistant special director, owner/executive director of a behavioral clinic founded in 2008
How did I fall into Autism? Answered a nanny ad while attending UT?
How did Neurodevelopmental Disorders become my 24/7 life? 2 Kids!
How did I fall into VR? 8 years ago and now I am your biggest advocate! I have some street cred?my husband is a VR Counselor?.
Be sure to include the following, your:
Name
Management unit in what region
Current struggle
Goal for this workshop
Introductions- Your Turn!
4
Course Agenda
Day 1 9-5pm
Day 2 9-5pm
9:00 – 9:15am Introductions
9:15 – 9:30am Neurodevelopmental Disorders and IDD
9:30 – 10:30am Specific Learning Disabilities
10:30 – 10:45am BREAK
10:45 – 12:15pm Attention Deficit/Hyperactivity Disorder
12:15 – 1:30pm LUNCH
1:30 – 2:45pm Autism Spectrum Disorder
2:45 – 3:00pm Co-Morbidities in Neurodevelopmental Disorders
3:00 – 3:15pm Tying it Together: ND Common Needs
3:15 – 3:30pm BREAK
3:30 – 4:15pm Working with Parents and Schools
4:15 – 5:00pm Testing your Knowledge of Day 1
9:00 – 10:00am Best Practices in Initial Contact & Application
10:00 – 10:30am Best Practices in Eligibility/Plan Dev
10:30 – 10:45am BREAK
10:45 ? 12:15pm Best Practices in Eligibility/Plan Dev (Premium)
12:15 – 1:15pm LUNCH
1:15 – 2:00pm Best Practices in Active Services (EWA)
2:00 – 2:45pm Best Practices in Active Services (ASD Supports/ABA)
2:45 – 3:00pm BREAK
3:00 – 4:00pm Final Review of Day 1 and 2 through Jeopardy Game
?
5
What is a Neurodevelopmental Disorder?
1. Autism Spectrum Disorder (ASD)
Attention Deficit/Hyperactivity Disorder (AD/HD)
Intellectual Developmental Disorders (IDD)
4. Specific Learning Disorder (SLD)
The 4 Neurodevelopmental Disorders are:
Groups of conditions with onset in the developmental period
Manifest early in development and characterized by deficits that produce impairments of:
Personal
Social
Academic
Occupational functioning
ND?s are the largest disability population we serve, currently, 36,000
ND?s make up 83% of all transition age.
Autism is the fastest growing ND.
Did you know?
6
Let?s test your pre-knowledge
Which one is the most common co-morbidity of attention deficit disorder?
IDD SLD ASD AD/HD
Which one effects your global ability to learn?
IDD SLD ASD AD/HD
Which includes sensory abnormalities as a core diagnostic criteria?
IDD SLD ASD AD/HD
If you saw someone eating a bowl of sugar, which one could they have?
IDD SLD ASD AD/HD
Did you know?
Neurodevelopmental Disorders
As of 2019
Neurodevelopmental Disorders
IDD ASD AD/HD SLD 6716 6164 7112 10779
7
Intellectual Developmental Disorder-IDD
A GDD is when an individual fails to meet expected developmental milestones in all areas. Such as walking, talking, puberty. For some, the delay is short term. Little is known of the exact causes.
Global Developmental Delay -GDD
Deficits in intellectual functions such as reasoning, problem solving, planning
Deficits in adaptive behaviors that require support in one or more activities of daily life such as communication, social participation and independent living
317 Mild May need ________ support in complex daily living tasks
318.0 Moderate Extended period of __________ is needed to master daily living tasks
318.1 Severe _________ supports for all activities of daily living
318.2 Profound _________on others for all areas of life
Did you know?
True or False A person with IDD ability to learn new concepts stops or at least slows around high school age
True or False A person must be able to learn the alphabet in order to read
True or False Counting cash and coins is a good money management goal
Bonus- What ND was most commonly misdiagnosed for IDD? Autism
some
teaching
Dependent
Requires
8
Specific Learning Disabilities
ICD-9-CM
315.00 Specific Learning Disorder, with impairment in reading
315.01 Specific Learning Disorder, with impairment in written expression
315.02 Specific Learning Disorder, with impairment in mathematics
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Specific Learning Disorder -SLD
impairment in reading (formerly known as Dyslexia)
Word reading accuracy
Reading rate or fluency
Reading comprehension
impairment in written expression (formerly known as Dysgraphia)
Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression
impairment in mathematics (formerly known as Dyscalculia)
Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning
10
Why the DSM 5 Change?
Elimination of IQ-achievement discrepancy
What does ?IQ- achievement discrepancy? mean?
Their IQ was compared to their achievement performance and if it fell within a prescribed range, they received a diagnosis of LD. This tended to under identify for those with higher IQ?s and over identified with lower IQ?s .
Dr. Pasternack, Assistant Secretary for the Office of Special Education and Rehabilitation Services (OSER) gave the following reasons:
IQ-discrepancy does not identify distinct groups of individuals who differ in characteristics, cognitive strengths and weaknesses, or response to intervention
Identification is further complicated by one-time assessments based on assumptions that LD is caused by intrinsic neurological difficulty as opposed to opposed to poor instruction.
11
Led to response to intervention (RTI)
Achievement, IQ and college?
A responsiveness to intervention approach to eligibility determination identifies students as having a learning disability if their performance does not change in response to validated intervention implemented with integrity.?
Ex: Exposure to intensive reading instruction should be used to distinguish between reading problems caused by cognitive deficits and those caused by poor reading instruction.
Schools are being told by research driven evidence to look beyond a single IQ ?number? in determining services. So what implication should this have for VR?
When should we order a psychological?
How do we use information found in a psychological?
Is there a grade level someone should be at in order to attend college?
Did you know?
Drive and motivation can make an ?average? IQ outshine others.
12
Group Activity: Pick a SLD!
Dyslexia
Dysgraphia
Dyscalculia
Auditory Processing
Disorder
13
Break -15minutes
We start back on time!
14
Attention Deficit/Hyperactivity Disorder
ICD-9-CM
314.00 AD/HD, predominantly inattentive presentation
314.01 AD/HD, predominantly hyperactive/impulsive presentation
314.01 AD/HD, combined presentation
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Attention Deficit/Hyperactivity Disorder ?AD/HD
The more someone with AD/HD concentrates, the less blood flow, occurs in their brain.
AD/HD is about underactivity in the brain . What are examples of self stimulating behaviors someone may engage in to ?stimulate? their brain?
What is happening in the brain?
Core symptoms:
Short attention span, distractibility
Disorganization with time and space
Procrastination
Poor internal supervision
Sugar and cocaine effect the same part of the brain.
What chemical is released? Dopamine
What chemical is low in someone with AD/HD? Dopamine
Did you know?
True or False? People with AD/HD cannot hyper focus.
True or False? Heritability of AD/HD is substantial.
True or False? AD/HD is correlated with a low IQ.
True or False? Girls are more likely to be diagnosed with inattentive.
True or False? People can outgrow an AH/HD diagnosis with treatment.
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How symptoms manifest behaviorally:
33% of people with AD/HD will not complete High School
52% of people with untreated AD/HD will engage in substance abuse
Did you know?
Inattention: wandering off task, lacking persistence, difficultly sustaining focus/follow through
Impulsivity: hasty actions that occur in the moment , without forethought may reflect the desire to for immediate rewards or inability to delay instant gratification
Hyperactivity: excess motor activity or excessive fidgeting, tapping, talking
What is executive functioning?
18
Oppositional Defiant Disorder: May resist work or school tasks that require self application because they resist confirming to others? demands. Their behavior is characterized by negatively, hostility and defiance. This must be differentiated from aversion to school or mental demanding tasks due to AD/HD.
Differential diagnosis, not AD/HD
Intermittent Explosive Disorder: AD/HD and IED share high levels of impulsive behavior, but IED show serious aggression towards others and they do not experience problems with sustaining attention.
Conduct Disorder: Is repetitive and persistent pattern of behavior in which basic respect of others or societal normal/rules are violated. ODD & IED will typically precede this diagnosis.
Disruptive Mood Dysregulation Disorder : Persistent negative mood in between impulsive aggressive outbursts, onset before 10 yrs.
19
7 Types of AD/HD according to Dr. Amen
How can this information guide your C & G?
| Type | Characteristics | Treatment |
| Classic | ||
| Inattentive | ||
| Over focused | ||
| Temporal Lobe | ||
| Limbic | ||
| Ring of Fire | ||
| Anxious |
Inattentive, distractible, hyperactive
Stimulant, high _____ diet
Stimulant, high _____ diet
Inattentive, distractible, without hyperactivity
Uses SPET Scans to view the brain:
measures activity
blood flow
Core ADD + excessive worry, can?t shift thinking, oppositional, tendency to be compulsive
Core ADD + memory/learning problems, mood stability, irritability can turn into rage
Core ADD + low energy, negative thinking, mimic depression symptoms
Core ADD + hyper activity +sensory sensitivity, mood cycles, periods of _____
Core ADD + frequent anxiety, physical stress symptoms, conflict avoidant
Stimulant + antidepressant, higher ____ diet
Stimulant + antiseizure, high _____ diet
Stimulant + antidepressant, high _____ diet
Stimulant + antiseizure + GABA, high _____ diet
GABA + antidepressant, high ______ diet
We underestimate the effects of our diet. The Miracle Pill- Netflix
carb
protein
protein
protein
protein
protein
protein
20
Group Activity: AD/HD Case Studies
21
12:15pm-1:30pm
LUNCH
This Photo by Unknown Author is licensed under CC BY-NC-ND
22
Autism Spectrum Disorder
ICD-9-CM
299.00 Autism Spectrum Disorder
315.39 Social (Pragmatic) Communication Disorder
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Autism Spectrum Disorder – ASD
Deficits in social and communication skills
Restricted, repetitive patterns of behavior, interests and activities
Sensory abnormalities
Did you know?
That a diagnosis of Autism can be made through specialized eye tracking equipment as long as a just a few months old?
no babbling or pointing by age 1
no single words by 16 months or two-word phrases by age 2
no response to name
loss of language or social skills
poor eye contact
excessive lining up of toys or objects
no smiling or social responsiveness
Early Indicators of ASD
True or False? Research supports a genetic causation.
True or False? Fragile X mimics some characteristics of Autism.
True or False? Autism is the ND most likely to be underemployed.
True or False? Aspergers and PDD-NOS are no longer diagnosed.
Autism
2010 2014 2019 1900 3600 7700
Social Interaction Deficits
Social Communication Deficits
Did you know?
People with Autism:
have a lack of social awareness & social ______,
will not imitate peers, i.e. pick up on social cues that others get by observing,
need social skills & norms explicitly taught to them because they do not learn by observation,
lack ___________ taking, does not know how to be ?in someone else?s shoes?,
have difficulties adjusting behaviors to fit the social context,
deciphering nonverbal cues and understanding unspoken rules,
have social _______ & social fears due to lack of social understanding and fear of the ?unknown?
People with Autism may have these types of communication deficits:
nonverbal (no verbalizations to a few utterances),
echolalia (repeating verbatim what they have heard, this can be delayed or instant),
low verbal (able to string phrases together, but consistent sentences are difficult),
________ impaired verbalization (no deficits in language abilities until they feel anxious),
Other deficits in social communication:
normal back & forth conversation, understanding the use of nonverbal body language or pragmatics in language (how to use language in social settings i.e. greetings, requests etc..),
Poor social skills directly impact their ability to communicate- don?t know what to say, so I don?t say anything or I only want to talk about my interest,
Rigid thought process impacts as well-I don?t know the ?right? or ?perfect? thing to say, so I don?t say anything
norms
perspective
anxiety
Anxiety
Rigid Thoughts, Resistance to Change
think in absolutes, i.e. __________, wrong or right- their brain struggles to see the ?grey? in life,
are logical thinkers and struggle to ?think outside the box? or engage in ?what if? conversations,
take words literally- careful using sarcasm and idioms, if you do, explain your words,
tend to get their ideas and thoughts stuck in a loop, many times a negative and illogical one,
have a poor ___________ to change due to their rigid thought process
Restrictive Interests, Activities
______ their interests, activities due to their rigid thought patterns and resistance to change, many have little appropriate leisure activities- further isolating them,
prefer to do what they are ________ to and don?t want to ?explore?,
can become ?little? professors in that interest,
struggle to find others that like exactly what they do or only want to talk ?at? not ?with? others on their preferred topic
Change
black & white
tolerance
Limit
exposed
Repetitive Patterns of Behavior
like ?sameness? in their ________ and in their environment (i.e.) eating with the same blue plate, same meal, same seat at the table meal after meal, day after day,
may ?self stim? i.e. rock themselves or,
like repetitive movement like watching a spinning fan or spinning an object or,
like repetitive activities like listening to the same music or watching the same movie over and over
Sensory Abnormalities
Most sensory abnormalities fall in these 2 types:
Objects, clothing and environmental demands are common to seek or avoid.
Common __________________ demands that cause sensory issues
lights
sounds
smells
temperature
pace- ie. busy or slow environments
social interaction required
structure and predictability
Did you know?
Smells that most of us would agree are good like a vanilla candle can be aversive to someone on the spectrum? OR something that tastes terrible to most, tastes good to someone with ASD?
Why do you think that is? How could this effect employment?
routine
avoids
seeks
environmental
Hypersensitive = ___________ sensory
Hyposensitive = ___________ sensory
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What is the Spectrum?
Level 1:
Level 2:
Level 3:
Did you know?
That with intervention, individuals can be moved up levels and even no longer qualify for a diagnosis of Autism.
In their regular education setting over 80% of the day (Inclusion)
DSM 5 says: ?requiring support?
In their regular education setting between 40-79% of the day (Resource)
DSM 5 says: ?requiring substantial support?
In their regular education setting less than 40% of the day (Self-Contained)
DSM 5 says: ?requiring very substantial support?
30
Houston, we have a problem?.how to de escalate
Immediately reduce demands, possible break from activity or social interactions
Use less words
Can format like this: If __________, Then ____________
Or
First ___________, Then _____________
To get more communication, structure the words
ex. ?Would you like to go X or Y?? (instead of what would you like to do next?)
?Do you want to go in 5 min or 10min??
To combat fear, take smaller steps, ?Just need to come talk to me for 5min? and build from there
Reduced verbal ability to speak
Sudden, persistent perseveration that can?t be redirected
Resistance more than usual
Increased self stimulatory behaviors or new ones
Sudden emotion- irritability, anger outburst or starts to shut down
Trouble in the water?signs of escalation
Fear of the unknown and change will be the biggest upfront barriers:
Give exposure to new places, people & activities for short bursts with little to no demands
Give the details! Provide expectations upfront, best done visually
Build trust- do what you say you will do
Give them a heads up- schedules change, that?s ok but let them know
*Deal with social skill mistakes immediately and use as teachable C & G moments
Prevention of behavior
31
Group Activity: ASD Case Studies
32
Co-Morbidities in Neurodevelopmental Disorders
33
Where does the co-morbidity start and stop?
Which is the most common? ________________________________
Which is creates the biggest barrier? ________________________________
Which one is the least treated? ________________________________
Which is the hardest to treat? ________________________________
Ask yourself?.
Learning Disabilities
Depression
Epilepsy
Tourette?s
Obsessive-Compulsive Disorder
Personality Disorder
AD/HD
Conduct Disorder
Anxiety
Mental Health: Anxiety & Depression
Intellectual Delay
Autism
ADHD
LD
IDD
ND
__
__
__
__
__
__
__
__
__
__
34
Tying it Together: ND Common Needs
35
What do they have in common?
What do they need?
Majority are transition aged
Learning difficulties
Higher rate of poor self esteem, learned helplessness, dependence
Co-morbidity of mental health issues (depression, anxiety)
Social skill deficits
Cognitive inflexibility
Low ability or inability to self regulate emotions
Low tolerance for change
Deficits in executive functioning
Did you know work is a form of intervention?
List at list 5 ways work can serve as intervention for a ND:
1.
2.
3.
4.
5.
To find out, answer these 2 questions :
What is the hardest job to typically obtain?
What is one of the common reason a person with ND loses a job?
Their 1st
Poor Social Skills
36
Break -15minutes
We start back on time!
37
Working with Schools and Parents
38
Schools and graduation
Students graduating by IEP, cannot be graduated until they meet one of the
following :
Met required state standards for graduation plan
Obtained full employment & doesn?t need ongoing supports
Mastered specific employability skills & doesn?t need ongoing supports
Attending college or post secondary training
Met aging out requirement
Commissioner?s rule 89.107
Students graduating on a Recommended Plan tend to struggle more?Why?
Focus on academics, therefore less opportunity in their degree plan for:
Social skills
Study skills
Vocational exploration/experiences
Making it even harder, many go straight to college and graduate without experiencing their first job.
Did you know?
Did you know?
By law, the district has to hold an ARD to consider student back in school, if one is requested.
Important!
Transition and NDs
Neurodevelopmental Disorders
ND Transition 25310 31133
39
What is their transition needs?
Transition planning
Thorough transition planning that addresses:
Social skill intervention
Stress tolerance
Career exploration
Early work experiences
Paid employment before graduating
Use a transition assessment and create your ?road map?
Every year evaluate, set goals, repeat
Transition is ever changing, be prepared to back up and reassess
Hormones will throw a wrench in it every time
Remember, they have a developmental delay
1. What education service center (ESC) is responsible for transition in Texas?
2. Who is responsible for transition coordination?
3. At what age should transition planning start?
Region 11- Transition in Texas Website
District transition coordinator and ARD Team
As soon as you know they have a disability?.but, legally by 14.
Mmmmm?.
Is mom going to work with you?
42
Parents and Caregivers
Parents that have ND characteristics can be helped by the same strategies ?..
Remember the genetic link
Start with Promoting Independence
Set expectation up from the start, you will talk with the customer alone
Start small and build up time
Communicate directly with the customer, parent is ?cced?
Give parents homework ideas on how can they promote independence
Grief and or years of being worn out can etch away at parents holding normal expectations
A reality check is good, ?You want him to go to UT for a business degree, but he is not able to call and make his own appointment with me?
Did you know?
Examples of ?homework? questions for parents to promote independence:
1.
2.
3.
4.
5.
43
Heads Up!
As we wrap up the day and test your knowledge?
Day 2
Neurodevelopmental Disorders 201
45
Walking Through the VR Process
46
Office Knowledge & Initial Contact
General knowledge
Does everyone in the office that can come in contact with a customer with Autism know the basics? What tool could you use to educate? Autism Office Flyer
COD
Does you office have a way to triage what cases need a specialist?
Who can you consult with?
My RPOC for the ND Team is: ________________________________________
Counselor on the ND Team closest to me: _______________________________
Where are other in agency resources?
1.
2.
3.
Who are the providers that work with NDs? How do you find this out?
Your Turn: Write a Social Story for how to text someone or get creative and use your own situation
47
Application
Strategies
Remove the ?Unknown?
No Demand Meeting
Email/Text Questions
Email Rules
I will email a person once and wait for a response. It is ok to send a follow up email if after a few days, I don?t hear back. It is not ok to be rude in my email even if I am irritated that the person took longer than I wanted to respond. People get busy and they aren?t trying to ignore me. If I constantly email someone, they will become upset with me and won?t want to respond at all.
Social Stories
Paying Attention in ND 201
I will pay attention in ND 201. Paying attention means I will put away my electronics and only check them periodically. I will respond to email or text briefly only when the messages are urgent. If I pay attention in ND 201, I will learn AMAZING information that will make my job easier. I need my job to be easier so I will pay attention in ND 201?.
Social Story Example: College student who ?stalked? his professor over a question.
Example: Use paper, dry erase board etc . to structure a distracted or anxious customer
48
Application
Example: Use sticky notes to structure perseverative talk.
?You can talk to me 3 times today about your new video game. Each time you do, you will hand me one of these sticky notes. When all the sticky notes are gone, then no more video game talk for today.?
Visual Strategies
Today we are going to:
Finish your application
Get you a pin number
Sign your paperwork
Make next appointment
Talk to you about your interests for 5min
Video game
Visual strategies do not have to be complicated ! In fact, you will be more likely to use them if they are simple .
Did you know?
Video game
Video game
49
Application
Visual Strategies
Tools:
VR Visual Process
Appointment Reminder
Level of Comfort Scale
Summary of VR Meeting
VR Visual Process
Use VR Visual Process to ?show? a customer what to expect
Appointment Reminder
Use to ?show? a customer what to bring to the appointment
50
Application
Visual Strategies
Tools:
VR Visual Process
Appointment Reminder
Level of Comfort Scale
Summary of VR Meeting
Level of Comfort Scale
Gives you an initial baseline of where they are on the ?spectrum?. Helps with communication so you can go deeper than the typical yes/no answers.
Summary of VR Meeting
Gives structure to the meeting, reminds everyone where they are in the process, says goal driven and a home
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