Emerging Milestones (EM) is a behavioral and educational treatment service; offering intervention plans for children from the Autism Spectrum Disorders and their families. Emerging Milestones has formed an alliance with specialists in the fields of: Psychology, Medicine, and Education. It is believed that this diversity enhances the ability to develop appropriate and successful treatment plans. [www.EmergingMilestones.com]
EM Educational interventions attempt to help children not only to learn academic subjects and gain traditional readiness skills, but also to communicate functionally and spontaneously, socialize with skills such as joint attention, gain cognitive skills such as symbolic play, reduce disruptive behavior, and generalize by applying learned skills to new situations. Several model programs have been developed, which in practice often overlap and share many features, including:
*early intervention that does not wait for a definitive diagnosis;
*intense intervention, at least 25 hours/week, 12 months/year;
*low student/teacher ratio;
*family involvement, including training of parents;
*structure that includes predictable routine and clear physical boundaries to lessen distraction; and
*ongoing measurement of a systematically planned intervention, resulting in adjustments as needed.
Several educational intervention methods are available, as discussed below. They can take place at home or school. A 2007 study found that program with weekly home visits by a special education teacher improved cognitive development and behavior. [cite journal |author=Rickards AL, Walstab JE, Wright-Rossi RA, Simpson J, Reddihough DS |title=A randomized, controlled trial of a home-based intervention program for children with autism and developmental delay |journal= J Dev Behav Pediatr |volume=28 |issue=4 |pages=308–16 |year=2007 |pmid=17700083 |doi=10.1097/DBP.0b013e318032792e] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills,cite journal |journal=Pediatrics |date=2007 |volume=120 |issue=5 |pages=1162–82 |title= Management of children with autism spectrum disorders |author= Myers SM, Johnson CP, Council on Children with Disabilities |doi=10.1542/peds.2007-2362 |pmid=17967921 |url=http://pediatrics.aappublications.org/cgi/content/full/120/5/1162 |laysummary=http://aap.org/advocacy/releases/oct07autism.htm |laysource=AAP |laydate=2007-10-29] and often improve functioning and decrease symptom severity and maladaptive behaviors;cite journal |journal=J Clin Child Adolesc Psychol |date=2008 |volume=37 |issue=1 |pages=8–38 |title= Evidence-based comprehensive treatments for early autism |author= Rogers SJ, Vismara LA |doi=10.1080/15374410701817808 |pmid=18444052] claims that intervention by age two to three years is crucialcite journal |journal= Harv Mag |date=2008 |volume=110 |issue=3 |pages= 27–31, 89–91 |title= A spectrum of disorders |author= Pettus A |url=http://harvardmagazine.com/2008/01/a-spectrum-of-disorders.html] are not substantiated.cite journal |author= Howlin P |title= Autism spectrum disorders |journal=Psychiatry |volume=5 |issue=9 |date=2006 |pages=320–4 |doi=10.1053/j.mppsy.2006.06.007]
Training Methodologies & Terminology
Applied behavior analysis
Interventions based on applied behavior analysis (ABA) focus on teaching tasks one-on-one using the
behavioristprinciples of stimulus, response and reward,cite journal |author= Howard JS, Sparkman CR, Cohen HG, Green G, Stanislaw H |title= A comparison of intensive behavior analytic and eclectic treatments for young children with autism |journal= Res Dev Disabil |volume=26 |issue=4 |pages=359–83 |year=2005 |pmid=15766629 |doi=10.1016/j.ridd.2004.09.005] and on reliable measurement and objective evaluation of observed behavior. There is wide variation in the professional practice of behavior analysisand among the assessments and interventions used in school-based ABA programs. Many interventions rely heavily on discrete trial teaching (DTT) methods, which use stimulus-response-reward techniques to teach foundational skills such as attention, compliance, and imitation. However, children have problems using DTT-taught skills in natural environments. In functional assessment, a common technique, a teacher formulates a clear description of a problem behavior, identifies antecedents, consequents, and other environmental factors that influence and maintain the behavior, develops hypotheses about what occasions and maintains the behavior, and collects observations to support the hypotheses. A few more-comprehensive ABA programs use multiple assessment and intervention methods individually and dynamically.cite journal |journal= Psychol Schools |year=2007 |volume=44 |issue=1 |pages=91–9 |title= Applied behavior analysis: beyond discrete trial teaching |author= Steege MW, Mace FC, Perry L, Longenecker H |doi=10.1002/pits.20208]
ABA has demonstrated effectiveness in several controlled studies: children have been shown to make sustained gains in academic performance, adaptive behavior, and language, with outcomes significantly better than control groups. A 2008 review of educational interventions for children whose mean age was six years or less at intake found that the higher-quality studies all assessed ABA, that ABA is well-established and no other educational treatment is considered probably-efficacious, and that intensive ABA treatment carried out by trained therapists is demonstrated effective in enhancing global functioning in pre-school children.cite journal |journal= Res Dev Disabil |date=2008 |title= Outcome of comprehensive psycho-educational interventions for young children with autism |author= Eikeseth S |doi=10.1016/j.ridd.2008.02.003 |pmid=18385012] A 2008 evidence-based review of comprehensive treatment approaches found that ABA is well-established for improving intellectual performance of young children with ASD. A 2008 comprehensive synthesis of early intensive behavioral intervention (EIBI), a form of ABA treatment, found that EIBI produces strong effects, suggesting that it can be effective for some children with autism; it also found that the large effects might be an artifact of comparison groups with treatments that have yet to be empirically validated, and that no comparisons between EIBI and other widely recognized treatment programs have been published. [cite journal |journal= J Autism Dev Disord |date=2008 |title= Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA young autism project model |author= Reichow B, Wolery M |doi=10.1007/s10803-008-0596-0 |pmid=18535894]
Pivotal response therapy
Pivotal response therapy or treatment (PRT) is a naturalistic intervention derived from ABA principles. Instead of individual behaviors, it targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations; it aims for widespread improvements in areas that are not specifically targeted.The child determines activities and objects that will be used in a PRT exchange. Intended attempts at the target behavior are rewarded with a natural reinforcer: for example, if a child attempts a request for a stuffed animal, the child receives the animal, not a piece of candy or other unrelated reinforcer. [Pivotal response therapy:
*cite book |title= Pivotal Response Treatments for Autism: Communication, Social, & Academic Development |author= Koegel RL, Koegel LK |publisher=Brookes |isbn=1557668191 |date=2006
*cite journal |journal= J Assoc Pers Sev Handicaps |year=1999 |volume=24 |issue=3 |pages=174–85 |title= Pivotal response intervention I: overview of approach |author= Koegel LK, Koegel RL, Harrower JK, Carter CM |doi= 10.2511/rpsd.24.3.174]
TEACCH "Treatment and Education of Autistic and Related Communication Handicapped Children," which has come to be called "structured teaching", emphasizes structure by using organized physical environments, predictably sequenced activities, visual schedules and visually structured activities, and structured work/activity systems where each child can practice various tasks. Parents are taught to implement the treatment at home. A 1998 controlled trial found that children treated with a TEACCH-based home program improved significantly more than a control group. [cite journal |author=Ozonoff S, Cathcart K |title= Effectiveness of a home program intervention for young children with autism |journal= J Autism Dev Disord |volume=28 |issue=1 |pages=25–32 |year=1998 |doi=10.1023/A:1026006818310 |pmid=9546299]
It is a therapeutic approach mostly derived by the proposal that individuals with autism are more apt to use and comprehend visual cues. Picture schedules are heavily focused on to encourage independence by being able to distribute step-by-step tasks. By being able to perform a task independently the individual is able to comprehend at a higher level.
The goal of TEACCH is to help autistic children fully develop into adulthood with the maximum autonomy and understanding of the world around them. Children acquire communication skills that enable them to relate to others, make independent choice about their own life, and maximizing their potential. The strategies taught in TEACCH do not work directly on behavior as it does in behavior modification, but on the core conditions that facilitate a learning experience. Behavior excesses and deficits are not directly treated, rather we want to comprehend why these behavior occurred in the first place. What is the underlying reason? Is it that the child is anxious, physically in pain, having difficulty with the task, going threw unpredictable changes, or bored, etc... By giving a meaning to communication, the person can then comprehend and express capabilities which will allow him/her to understand better what is being told or asked and to express needs and feelings in more appropriate ways. [Emerging Milestones Training Manual]
Relationship Developmental Intervention (RDI)
RDI does not derive from behaviorism; rather it views autism as being caused by a lack of connections between neurons in the brain. It is believed that the authentic emotional relationship facilitated through RDI changes neurology and creates flexible thinkers.
The core belief of RDI is that the fundamental basis to enhancing the quality of life for autistic individuals rests in developing self-motivated intelligence. Autistic individuals must be gradually and systematically exposed to authentic emotional relationships. This will steadily develop motivation and success while rectifying common autistic deficits.
Building social connections by making friends, developing empathy, and sharing ideas and views with others is the main focus of RDI.
Dr. Steven Gutstein is the founder of RDI. He identified 6 abilities in dynamic interactions as:
1) Emotional referencing- Emotional feedback system used to understand subjective experiences of others.
2) Social coordination- Participating in spontaneous relationships linking collaboration and exchange of emotions while observing and regulating behaviors.
3) Declarative language- Expressing curiosity, inviting interactions, sharing feeling and synchronize actions with others by using non-verbal and verbal language.
4) Flexible thinking- Quickly being able to adjust plans based on changing circumstances.
5) Relational informational processing- Attain meaning out of problems when looking at the big picture.
6) Foresight and hindsight-.Capacity to reflect on past and predict possible and realistic pictures of the future. [Emerging Milestones Training Manual, Page 15]
The DIR/Floortime model uses a framework based on developmental approaches, individual differences, and relationships. It targets autism's core impairment of social reciprocity with a variety of therapies, including sensory-motor, language, social functioning, occupational, and speech therapy, along with family support and floortime play sessions; the therapies are tailored to the individual child. Published scientific evidence is lacking for this approach.
Floortime follows a developmental approach that works on helping children climb the developmental ladder to success. This is achieved by: creating experiences that promote the mastery of milestones, dealing with each child’s specific challenge and facilitate development, and finally maximizing interactions with children by creating a family pattern of emotional and intellectual support.
Floortime is simply spending a 20-to-30-minute period on the floor interacting and playing with the child.
Human relationships are vital to a child’s development. The brain and the mind do not fully develop without the presence of relationships. Self-esteem, initiative, creativity, logic, judgment, and abstract thinking all develop stronger with relationships.
By following the child’s interests and impulses, you as the adult, are able to capitalize on the child’s emotion. You can help him/her learn how to attend to you, engage in dialogue, and connect emotions and intent with appropriate behavior. By working this way you make it possible for your client to embark on relating in a more meaningful, spontaneous, and flexible way.
Each Floortime interaction is an opportunity to build the gap between emotion and behavior seen in autistic children. Follow your client’s interests and motivations and observe where he/she takes you. [Emerging Milestones Training Manual, Page 16]
Picture Exchange Communication System (PECS)
This is a form of augmentative and alternative communication (AAC). When children lack verbal and speech skill development, pictures of favorite food, toys, people, etc. provide that alternative ability to communicate. The child picks the picture of his desired choice and hands it to the person he wants to communicate with. The communication partner then hands the item to the child in exchange for the request. This can be used in the natural environment as well. If a child sees an item he likes, he can point out the picture to another person to communicate. The goal is the help the child understand that communicating his/her needs will lead to a positive response. PECS consists of 6 phases:
Phase 1: Physical exchange: Child requests a card the has a picture of what he wants, therapists acknowledges this and exchanges picture for item.
Phase 2: Distance and Persistence: Therapists moves slightly away to have the child come closer.
Phase 3: Correspondence Checks: The child is given 2 cards and chooses what it is he/she really desires.
Phase 4: Sentence Structure: child is given a card reading “I want__” to encourage verbal communication along with the exchange.
Phase 5: Request: Therapists asks, “What do you want?” Child hand therapist the card saying “I want__”
Phase 6: Discrimination Between the Label and the Request: Generalize the new skill and add new reciprocal communication, “I see__”. Child will learn to communicate observations, experiences and needs. [Emerging Milestones Training Manual,Page 18]
A form of communication that teaches others how to recognize opportunities when it presents itself . This is taught to increase language skills. This provides the child with communicative intent ( a reason, function that drives specific behaviors).
How to capture an EO: take advantage of naturally occurring situations. ex: Child comes inside from the park and wants water, capture the opportunity for a request.
How to contrive an EO: setting up situations or manipulating the environment to increase communication. ex: Hold the child's reinforcer in your hand and make it look or seem more enticing. The child will then have a stronger desire to obtain the item and may ask “help” “my turn” or “can I have” or “item name.”
EO’s can be contrived further by setting up a desired toy in a high location and has to request permission to get it. You are setting up a context to manipulate the situation in a way to encourage communication
Individualized Family Service Plan (IFSP)
The IFSP is geared for children who show symptoms of risk or are at risk from birth to three years of age. This meeting documents and guides the early intervention process for children with disabilities and their families. Family members and service providers work together to discuss services that would be most beneficial to each individual unique family at the IFSP.
The IFSP is in writing and will concern statements regarding:
The child's present levels of physical development, cognitive development, communication development, social or emotional development, and adaptive development. The family's resources, priorities, and concerns relating to enhancing the development of the child with a disability; .The major outcomes to be achieved for the child and the family; the criteria, procedures, and timelines used to determine progress; and whether modifications or revisions of the outcomes or services are necessary; Specific early intervention services necessary to meet the unique needs of the child and the family, including the frequency, intensity, and the method of delivery;The natural environments in which services will be provided, including justification of the extent, if any, to which the services will not be provided in a natural environment; The projected dates for initiation of services and their anticipated duration; The name of the service provider who will be responsible for implementing the plan and coordinating with other agencies and persons; and Steps to support the child's transition to preschool or other appropriate services.
U.S. Department of Education rules (1993) require that non-Part C services needed by a child, including medical and other services, are also described in the IFSP, along with the funding sources for those services. The statute allows parents to be charged for some services. If a family will be charged, this should be noted in the IFSP.
Individual Education Plan(IEP)
This is considered a legal document between the parents of a client and his/her school district designed to meet the child’s unique individual needs. Guarantees the necessary supports and services that will be provided for the child.
The IEP must contain the clients present levels of educational performance. Personal information about the child's strengths and needs will be taken from those working closely with the child, comments will be considered from all associated with t he child, observations and results from special education evaluation and district wide tests will be analyzed, and any other concerns of the child's developmental level and behavior will be discussed.
Services that will be provided based on the child’s specific needs are outlined and addressed. Measurable goals that can realistically be accomplished in one year are written up. “Goals should help her be involved and progress in the general curriculum and may be academic, social, behavioral, self-help, or address other educational needs.”
The law now states that the child’s IEP must include “a description of how the child’s progress toward the annual goals … will be measured and when periodic reports on the progress the child is making toward annual goals will be provided” — for example, at the same time report cards are issued for all students.
Once issues have been agreed on and the document is written, and action plan is created. The school district is obligated to provide a free appropriate public education (FAPE) in the least restrictive environment (LRE). Special education is considered to be a set of services. Services, goals and objectives are identified.
Other issues discussed in an Autism specific IEP meeting are maters such as: When services will begin, where and how often they'll be provided, and how long they'll last, supports and strategies for behavior management, language and communication needs, and necessary modifications in the general education or special education setting that may be needed, etc.
An IEP team includes: Clients parents, General Education teacher(s), a special education teacher, an individual to interpret evaluation results, a representative of the school system, administrators and all other individual professionals who are involved in the goal to aide in progress to the child’s plan.
Communication interventions fall into two major categories. First, many autistic children do not speak, or have little speech, or have difficulties in effective use of language. Interventions that attempt to improve communication are commonly conducted by speech and language therapists, and work on joint attention, communicative intent, and alternative or augmented communication methods such as visual methods. A 2006 study reported benefits both for joint attention intervention and for symbolic play intervention, [cite journal |author= Kasari C, Freeman S, Paparella T |title= Joint attention and symbolic play in young children with autism: a randomized controlled intervention study |journal= J Child Psychol Psychiatry |volume=47 |issue=6 |pages=611–20 |year=2006 |pmid=16712638 |doi=10.1111/j.1469-7610.2005.01567.x cite journal |title=Erratum |date=2007 |quotes=no |journal= J Child Psychol Psychiatry |volume=48 |issue=5 |pages=523 |doi=10.1111/j.1469-7610.2007.01768.x] and a 2007 study found that joint attention intervention is more likely than symbolic play intervention to cause children to engage later in shared interactions. [cite journal |author= Gulsrud AC, Kasari C, Freeman S, Paparella T |title= Children with autism's response to novel stimuli while participating in interventions targeting joint attention or symbolic play skills |journal=Autism |volume=11 |issue=6 |pages=535–46 |year=2007 |pmid=17947289 |doi=10.1177/1362361307083255]
social skillstreatment attempts to increase social and communicative skills of autistic individuals, addressing a core deficit of autism. A wide range of intervention approaches is available, including modeling and reinforcement, adult and peer mediation strategies, peer tutoring, social games and stories, self-management, pivotal response therapy, video modeling, direct instruction, visual cuing, circle of friends, and social-skills groups. [cite journal |author= Matson JL, Matson ML, Rivet TT |title= Social-skills treatments for children with autism spectrum disorders: an overview |journal= Behav Modif |volume=31 |issue=5 |pages=682–707 |year=2007 |pmid=17699124 |doi=10.1177/0145445507301650] A 2007 meta-analysis of 55 studies of school-based social skills intervention found that they were minimally effective for children and adolescents with ASD, [cite journal |author= Bellini S, Peters JK, Benner L, Hopf A |title= A meta-analysis of school-based social skills interventions for children with autism spectrum disorders |journal= Remedial Spec Educ |volume=28 |issue=3 |date=2007 |pages=153–62 |doi= 10.1177/07419325070280030401] and a 2007 review found that social skills training has minimal empirical support for children with Asperger syndromeor high-functioning autism.cite journal |journal= J Autism Dev Disord |date=2008 |volume=38 |issue=2 |pages=353–61 |title= Social skills interventions for children with Asperger's syndrome or high-functioning autism: a review and recommendations |author= Rao PA, Beidel DC, Murray MJ |doi=10.1007/s10803-007-0402-4 |pmid=17641962]
* [http://www.EmergingMilestones.com Emering Milestones]
* [http://www.PHP.com Parents Helping Parents]
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