The Child as a Whole Why Behavioral and Biomedical Interventions are both Critical to Growth and Recovery

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The Child as a Whole:
Why Behavioral and Biomedical Interventions are both Critical to Growth and Recovery Doreen Granpeesheh, Ph.D. B.C.B.A-D
Center for Autism and Related Disorders, Inc
Today’s Presentations
What is Autism: A whole body condition The Synergistic Effects of ABA and Biomedical Interventions working together
 Sudden and dramatic changes in behavior when medical interventions are put in place
• Case Studies
What is ABA (Applied Behavior Analysis)
 What is good ABA?
• How can you gain access to it?
What is Autism?
 Pervasive Developmental Disorders
 Impairments in two or more areas of development
• Autism
    Impaired Social Interaction, Impaired Communication Restricted, Repetitive Behaviors 6 or more symptoms
• Asperger’s Disorder
 Impaired Social Interaction  No Language delay  No Cognitive delay
 Delays in all three areas (Social, Communication and Stereotypy)  Fewer than 6 symptoms
What is Autism?
 My child is delayed in language  My child has no eye contact
Social Behavior:
 My child doesn’t interact with anyone  My child doesn’t play with others
 My child does repetitive behaviors (lining up objects, opening closing door, turning on and off the lights)  My child is inflexible and needs routines
Anything else? Challenging Behaviors? Sensory Sensitivities? Medical Illnesses?
Minimize Exposure Genetic Predisposition To Toxins
Treat the Underlying Medical Disorders
Metals Pesticides Antibiotics
Physical Conditions Oxidative Stress Decreased Methylation Immune Dysfunction GI Inflammation Brain Disorders Hypoperfusion Hypo and Hyper sensitivity to stimuli Different Learning Patterns Behavioral Symptoms Delayed Language Delayed Social Skills Stereotypy
Teach New Learning Patterns
Reduce/Eliminate Symptoms
Minimize Exposure to Toxins
Make sure your physician only uses antibiotics when necessary Avoid pesticides (go organic) Spread out vaccinations to reduce stress on immune system Check for metal toxicity to determine need for chelation (toxic metal assay, porphyrins)
Treat Underlying Medical Illness
Immune Markers
 Check for cell mediated immune activation (neopterin/biopterin)  Check for Strep Titers
• ASO: Antistreptolysin O • anti-DNase B: Anti-Deoxyribonuclease B
 Immunoglobulin Subsets (Antibodies that respond to bacteria, viruses, fungus, etc)  Vaccine Titers
Discuss Possible Treatments with your physician: IVIG, Spironolactone
Treat Underlying Medical Illness
Oxidative Stress Markers (reduced glutathione: found in every cell…helps neutralize free radicals)
 To identify need for Anti Oxidants
Decreased Methylation/transulfation (fasting plasma cysteine or methionine)
 To identify possible benefit of methyl B12
Treat Underlying Medical Illness
Evaluate and Treat GI Disorders
 Nutrition  Diet  Medication (anti-inflammatory, steroids, anti-fungals)
Reduce Hypoperfusion
Teach New Learning Patterns
Evaluate need for modified sensory input
 Visual  Auditory  Tactual
ABA: Applied Behavior Analysis
 “30 years of research demonstrated the efficacy of Applied Behavioral methods in reducing inappropriate behavior and in increasing communication, learning and appropriate social behavior”
Surgeon General, 1999
ABA and Biomed working together
Medical Treatment Eliminate Triggers Stabilize condition Achieve Health
ABA Increase Skills Decrease Challenging Behaviors Generalize to Daily Living
Because a healthy child sleeps better, feels better and can learn better!
Why would a behaviorist care about biomedical interventions?
1990: Andrew was diagnosed with Celiac… we placed him on a diet and he recovered within a year! 1992: I began to notice a pattern of children with extremely high use of antibiotics! This must be leading to some abnormal flora! 1993: Emily had fungus on her nails… treated with antifungals, her behavior changed drastically!
Preliminary Outcome Study:1996
79 children 63 boys 16 girls
Average age at intake: 39.1 months Average IQ at intake: 76.8 (borderline) Length of time in treatment: 3 years
Preliminary Outcome Study:1996
High Intensity
More than 25 hours/week 44 children
Low Intensity
Less than 25 hours/week 35 children
Matched on age, IQ, language, adaptive behavior
Results: Outcome 1996
Mean Client IQ Pre- and Post-Treatment
100 IQ Standard Score 95 90 85 80 75 70 Low Intensity
1 Pre-Treatment 2 Post Treatment
High Intensity
Mean Adaptive Functioning Pre- and Post-Treatment
100 Vineland Standard Score 95 90 85 80 75 70 65 60 Pre-Treatment
High Intensity
Low Intensity
Post Treatment
Normal Cognitive Functioning
WPPSI: Pre- & Post-ABA Early Intervention
130 120 110 100 90 80
Pre-Test Post-Test
Intelligence Quotient
70 60 50 40 30 20 10 0 20 22 27 29 29 30 30 31 31 31 32 34 38
Average Therapy Hours Per Week
Why didn’t we publish this?
1996 Outcome Study Confounding Variable:
• A higher percentage of children in the high intensity group were receiving biomedical interventions! • Was the improvement in IQ and adaptive skills due to ABA or due to the medical interventions or a combination???
1987: Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children
Experimental Group: N=19
47% hours/wk 40 Recovered! 3 yrs 10 hours/wk 10 hours/wk UCLA/NPI 3 2% Recovered yrs 3 yrs
Control Group 1: N=20
Control Group 2: N=20
Children with Autism DO Recover! There is NO magic pill It is hard work and can take a long time Let’s look at some case studies of children who improved significantly with a combination of medical and behavioral treatment
Mathew R
Diagnosis: Autism Intake:
 Age: 3.5  Deficits: no eye contact, speech consisted of 5 one word requests, tantrums by throwing self on floor and screaming, no interest in peers, not toilet trained, visual and ritual ssb occurred 90% of time
    1 year 7 months with CARD Average intensity of 40 hours/week GFCF and probiotics Anti-Fungal medications (Diflucan, Nistatin)
 Age: 5.1  In typical preschool with aide only for social interactions  Maintains conversation, asking for information, mand, tact and answer why/because questions, plays with peers up to 5 minutes interactively, very advanced in academic skills, few visual ssb, no tantrums anymore.
Mathew: challenging Behaviors
350 300 250
Diflucan + Nystatin + Probiotics
200 150 100 50 0 Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb
Tantrums Visual SSB
Non-Compliance Verbal SSB
Screaming Ritual SSB
Diagnosis: Autism Intake:
 Age: 2.11  Deficits: receptive vocabulary of 10 words, 3 expressive words used for needs (juice, open, ball), no eye contact, severe tantrums, crying, aggression and elopement, ssb included gazing, mouthing objects and toe walking.
 1 year 10 months with CARD to date  Average intensity of 30 hours/week  Specific Carbohydrate Diet
 Age: 4.9  In typical preschool with aide  175 mastered receptive labels, mands and tacts with all items using full sentences, maintains eye contact up to 8 seconds, responds to name by making eye contact and saying “yes” or ‘what”, answers 23 social identification questions, interacts with adults average of 10 minutes/peers 2 minutes. Ssb reduced but still exist, aggression and noncompliance have extinguished.
D.R.: New Skills per month
ABA + IgG Allergy Elimination Diet + Feingold Diet + Rotation diet
ABA + Specific Carbohydrate Diet
New Skills per Month
200 150 100 50 0 Nov-03 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04
D.R.: Cumulative Skills
ABA + IgG Allergy Elimination Diet + Feingold Diet + Rotation diet ABA + Specific Carbohydrate Diet
Cumulative Skills per Month
1200 1000 800 600 400 200 0
D.R.: Stereotypy per month
ABA + IgG Allergy Elimination Diet + Feingold Diet + Rotation diet ABA + Specific Carbohydrate Diet
Frequency of Stereotypy per Month
800 700 600 500 400 300 200 100 0
M onths
Visual SSB Verbal SSB Oral Motor SSB Tactile SSB
D.R.: Aggression per month
Frequency of Aggression per Month
100 90 80 70 60 50 40 30 20 10 0
ABA + IgG Allergy Elimination Diet + Feingold Diet + Rotation diet
ABA + Specific Carbohydrate Diet
Diagnosis: Asperger’s Syndrome Intake:
 Age: 3.4  Deficits: poor eye contact, extensive vocabulary but did not use language with peers, self-isolated at school, severe tantrums, non compliance and aggression with family, visual self-stimulatory behaviors, severe ritualistic behavior, no Theory of Mind
    10 months with CARD Average intensity of 10 hours/week Lexapro Pro DHA and CorOmega
 Age: 4.2  In typical kindergarten with no aide  Initiated conversations with peers, many friends, no tantrums or aggression, very advanced in academic skills and very popular in school
Emma: Challenging Behaviors per month
ABA + Lexapro
7 6 5 4 3 2 1 0 April May June July Aug Sept Oct
ABA + ProDHA + Coromega
Frequency per Session
Ritual SSB
Emma: New Skills per month
ABA + Lexapro
ABA + ProDHA + Coromega
New Skills per Month
100 80 60 40 20 0 Mar 04 April 04 May 04 June 04 July 04 Aug 04 Sept 04 Oct 04 Nov 04 Dec 04
A. D.
Diagnosis: Autism Intake:
 Age: 2.11  Deficits: had 3-4 word utterances but no spontaneous language, selfisolated around peers, no safety awareness, toe walking, licking hands, had difficulty inhibiting responses and would often touch people’s hair or clothing.
    3 year with CARD Average intensity of 25 hours/week Anti-fungals Chelation
 Age: 5.11  In typical kindergarten without aide  Initiates, joins, transitions conversations with peers, has many friends, good understanding of others perspectives, no challenging or selfstimulatory behaviors present. Normal range on all exit testing (IQ, language, TOM, EF)
A.D.: Challenging Behaviors per month
ABA + Antifungal + Chelation
Frequency per Hour
12 10 8 6 4 2 0 June Jan March June May July Nov Dec Feb Oct Sept April May Aug
M onth
Leaning Screaming
Elopement Running
Fidgeting Grabbing
A.D.: New Skills per month
ABA + Antifungal + Chelation
New Skills per Month
0 June Feb March June Jan Oct Sept April July May Aug Dec Nov
M onth
- 2 year old male - Completed 80 dives in 14 weeks - Mother reported tremendous gains in
language and socialization; significant changes were also noted by examiner during post-testing. - Supervisor reported that participant acquired many skills since starting the study.
ADOS Lower scores are better
14 12
Total Score
Pretest Post-test Autism Spectrum Cutoff
Autism Cutoff
4 Significant improvement on score Commication and Socialization score on the ADOS; both in autism spectrum range
ABC Lower is better
Aberrant Behavior Checklist
120 100
80 Irritability/Agitation Score by Area Lethargic/Withdrawal 60 Significant decrease in total score near end of study Stereotypic Beh Hyperactivity Inappropriate Speech 40 Total Score
1 2 k1 k2 k3 k4 k5 k6 k7 k8 k9 0 1 2 3 4 k1 W ee Co m pl k1 k1 k1 k1 BL BL W ee W ee W ee W ee W ee W ee W ee W ee W ee et io n
W ee
W ee
W ee
W ee
What do we learn from these Case Studies?
A variety of medical interventions worked for these children Each child benefited from a different type of intervention Autism is a “Spectrum Disorder”…children with Autism are very different from each other! Will these interventions work for your child?
 We simply don’t know!
Next Steps in the Medical Treatment of Autism
We need to do studies that show changes across groups of children
 Exp: all children exposed to MB12 improved  This is difficult (if not impossible) because the children are all different from each other!
Therefore, we need to find PHENOTYPES of Autism
 What type of child does well with MB12?  Which children benefit from chelation?  Who needs a course of HBOT?
What you can do as a parent
Look for biomarkers that indicate what medical treatment your child needs Understand the lab results your physician orders Try one intervention at a time Measure the change in behavior with each intervention Stick with a plan! DO ABA! IT WORKS FOR ALL KIDS
What is Applied Behavior Analysis
ABA is based on the principles of
Operant Conditioning Theory:
“Human Behavior is affected by events that precede it (antecedents) and events that follow it (consequences)”
Change these events…change Behavior!
What does that mean?
In ABA, we manipulate reinforcers in order to increase functional and adaptive behaviors, and decrease challenging behaviors. We give reinforcers when a good (adaptive) behavior occurs We remove reinforcers when a bad (challenging) behavior occurs
Reinforcers make the world go round!
If a child wants a toy and he cant say “I want that toy”, what do you think he will do to get the toy? He will grab, hit, or do what ever it takes to get the toy! When he hits and gets the toy, he just gained access to a reinforcer for hitting…he got the toy! From now on, he will learn to hit in order to get toys!
Replacing Challenging Behavior with Appropriate Behavior
Johnny wants a Johnny sees a toy! He doesn’t Toy he wants know how to ask nicely! Johnny hits Johnny asks for his sibling The toy and grabs the toy Johnny gets Johnny gets the the toy and toy and learns learns that that asking is hitting is Effective! effective!
What if Johnny does NOT get the toy when he hits And We teach him to ask nicely when he wants a toy?
Everything we do is to Get good stuff or Avoid bad stuff!
Give Remove Good Stuff + ReinforcementResponse Cost Extinction Behavior Behavior Bad Stuff Punishment Behavior - Reinforcement Behavior
What behavior do we want to change?
     Language Play Social Skills Theory of Mind Executive Functions
 Self Stimulatory Behs  Maladaptive Behs
• Tantrums • Aggression • Noncompliance
Skill Repertoire Instruction
Behavior Management
The Secret to successful ABA
The key is to teach appropriate skills! If a child has appropriate skills, and they are easy to do, he will not engage in challenging behaviors! We cannot simply “extinguish” challenging behaviors without replacing them first, with appropriate skills!
Applied Behavior Analysis or The CARD Program
Skill Repertoire Building Curriculum Assessment Teaching Paradigm Behavior Management Defining Problem Behavior Functions of Behavior Functional Behavioral Assesment FluencyBased
Teaching Procedures
Function-Based Treatment
Emergency Interventions
Prompting/ Fading
Discrimination Training
Replacement Behavior
Antecedent Modifications
Consequence Manipulations
Evaluation of Tx Effectiveness (Data Collection & Analysis)
Generalization & Maintenance
Shaping Knowledge Through Individualized Life Learning Systems (SKILLS)
What is SKILLS?
 Trains “how to” do ABA (the techniques)
 Every child is different…what do I teach my child?  Assesses child’s known and unknown skills through questions directly tied to CARD I Curricula
CARD I Curricula
 Provides “what to” teach
Skill Repertoire Instruction
Discrete Trial Training Prompting Shaping Chaining Reinforcement Errorless Learning Natural Environment Training Fluency Based Instruction
This is HOW we teach skills…This is the CARD E-Learning Modules
What skills does my child need?
 Skills Assessment
• What skills does my child have?
• Standardized global assessments
 IQ  Language  Adaptive
• CARD Assessments
     Language Play Executive Fxns Gross Motor Adaptive Skills Social Skills Social Cognition Self-Help Fine Motor Academic Skills
• Curriculum designed to meet child’s needs
The CARD Curriculum
School Skills
Executive Cognition Functions
Social Skills Motor Skills
The CARD Curriculum
By Emerging Age and Verbal Operant:
0-11 mos. Choices Listen to/Tell a StatementBody Parts Fast Mapping Story Statement Locations Following Functions 4:0-4:11 yrs. Instructions Negation Objects Describe by Gestures Plurals Opposites Category/Feature/ Making Recalling Events Prepositions Function Requests Sound Speed & Pronouns Phonic Same/ People Duration 2:0-2:11 yrs. Different Sound Syllable Adverbs StatementDiscrimination Segmentation AttributeQuestion Verbal WhObject What Goes With Imitation Discrimination Conditionality 5:0-5:11 yrs. Yes/No 3:0-3:11 yrs. Deliver a Observational 1:0 – 1:11 yrs. Minimal Pairs Message Learning Actions Same/Different Features Syntax Asking for Sequences Gender Information Sound Changes I Have/ISee Categories
The CARD Curriculum
Features of a Comprehensive Play Skills Program
 Modeled after the development of
play skills in
typically developing children Breaks down each type of play into its own systematic and comprehensive program Sequential format Programs may be used individually, concurrently, or cumulatively
Play Curriculum
Sensorimotor Play Task Completion Play Beginning Play Initiating and Sustaining Play Block Imitation Structure Building Constructive Sand and Water Constructions Play Clay Constructions Arts and Crafts
Early Social Games Read-to-Me Books & Nursery Rhym Interactive Music and Movement Play Treasure Hunt Card and Board Games Locomotor Play Peer Play
Audio and Video Play Computer Play Electronic Play Video Games
Pretend Functional Pretend Play Play
Symbolic Play Imaginary Play Sociodramatic Play
Adaptive Curriculum Personal
Feeding Toileting Undressing Unfastening Dressing Preventing Spread of Germs Bathing Fastening Teeth Care Hair Care Nail Care Health Care
Pet Care Setting & Clearing Table Telephone Skills Tidying Meal Preparation Cleaning Gardening Laundry School Backpack Prep Making a Bed
Domestic Adaptive
Safety Community
Shopping Restaurant Readiness Safety Awareness Safety Equipment
Motor Curriculum
Oral Motor
Visual Fine
Sitting Standing Walking Running Jumping Hopping
Ocular Motility Binocular Vision Skills Visual Perception
Hand Skills Coloring Pre-Handwriting Drawing Cutting with Scissors
Crawling / Creeping Riding Foot-Propelled Vehicles Rolling Over Rolling / Throwing / Dribbling Stairs and Climbing Riding a Tricycle / Bicycle Balance Beam Swinging a Bat / Racquet / Paddle Kicking Physical Education Readiness Catching
Visual Form Constancy
Match the picture on top with one of the four choices. 1.
Visual Form Constancy
What is added to the first picture to make the second picture? 1. First Picture to Second Picture
First Picture to
Second Picture
First Picture
Second Picture
Visual Figure-Ground Discrimination
How many times is the number 8 in the above picture? 7 times 10 times 2.
8 times
5 times
How many times is the number 6 in the above picture? 10 times 4 times 3.
5 times
1 time
How many times is the number 9 in the above picture? 9 times 3 times
15 times
2 times
Visual Closure
Draw the missing parts of the picture on the right. Color the picture on the left. 27. Left Right
The CARD Curriculum
School Skills
Number Concepts Language Arts 1 Rote Counting Language Arts 2 Reading Reading Numerals Visual Discrimination of Symbols Writing Manuscript Numeral Comprehension Science Printing Symbols Ordinal Position Reciting Alphabet Physical Education Uppercase Letters Personal Data Numerals in Sequence Lowercase Letters Lowercase Letters Addition Word Recognition History Letters Uppercase Subtraction Letters Advanced Counting Reading Orally Studies Social in Sequence Reading Comprehension Dictated Letters Money Book Topography Simple Sentences Time NonAcademic Story Comprehension of Printing Quality Story Summarizing Skills Text Comprehension
The CARD Curriculum
 Meta-cognition: Identifying your own …  Social Cognition: Inferring others’…
Thoughts Knowledge Desires Beliefs Intentions
Classic Test of Social Cognition “Sally-Anne” or False-Belief Task
Where will Sally look for her ball? Where does she think her ball
“Typical” Meta and Social Cognitive Development
First few months: Sense of Self
9 months: Joint Attention / Social Referencing 15 months: Pretence 18 months: Desire / Intention 2 years: Emotion 3 years: Knowing / Thinking 4 years: Belief / False-Belief 5 years: Intention – Accident vs. Purpose
Cognition Curriculum
13 Lessons
Physical States Detecting Sarcasm
Intentions Deception
Emotions Cause & Effect Senses
Beliefs Thinking Knowing
Sensory Perspectiv e Taking Desires Preference s
Social Skills Curriculum
Social Skills
Social Language Greetings and Salutations Non-Vocal Social Behavior Social ID Questions Eye Contact Prosody Non-Vocal Imitation Non-Vocal Regulating Others Body Language & Behavior Absurdities Social Facial Expressions Conversational Gestures to Figures of Speech Regulate Social Interaction Social SocialAudience Interaction Physical Context of Conversation HumorAbsurdities and Jokes Language to Conversation Apologizing Listening What’s Wrong? Assertiveness Initiating Conversation Compliments Joining Conversation Cooperation & Negotiation Maintaining Conversation Group Group Related Skills Social Gaining Attention Social Skills Repairing Conversation Related Responding in Unison Introductions Interaction Transitioning Topics of Conversation Group Discussion Skills Levels of Friendship Ending Conversation Sharing & Turn Taking Social Rules Self Esteem & Borrowing Lending Compliance Dealing with Conflict Social Following Rules Positive Self-Statements Self Esteem Rules Community Rules Social Context Winning & Losing Social Politeness & Manners Constructive Criticism Responding to Social Cues Context Learning Through Observation
The CARD Curriculum
What is Executive Function?  Process that underlies goal directed behavior
Goal Directed Behavior Involves… Visualizing situation Identifying desired objective Determining plan to meet objective Monitoring progress to goal Inhibiting distractions
Executive Functions
Executive Functions Curriculum
Waiting, Physical / Motor, Vocal, Inhibition Pencil / Paper
Flexibility/ Set-Shifting
Executive Functions
Task / Social Goal Setting, Previewing, Task Initiation, Monitoring Progress, Time Management, Planning Organizing Materials, Using a Planner, Self-Organization
Problem Problem Solving Emotions, Reinforcement Control, Solving Non-Social,
Study Skills, & Flexibility Social
Meta-Cognition MetaMeta-cognitive Planning, Cognitive Self-Evaluation, Meta-memory, Planning Self-Monitoring of Attention,
Non-Social, Social, Flexibility Social –Cognitive, Attention Situational Social Orienting, Joint Attention, Sustained, Divided, & Alternating Attention, Determining Attention Saliency, Depth of Processing, Paraphrasing, Task Persistence
Visual, Spatial, Auditory, Episodic, Working
Memory Associative, Memory
Children’s Color Trail Test
Stroop Activities
A good ABA program requires good assessment to determine exactly what your child needs to learn! A good ABA program needs a lot of hours! Don’t do 5 hours of ABA when 40 hours are recommended! This is like taking 5 mgs of a drug that has shown to be effective at 40 mgs! It wont work!
A 4 year progression
Year 1:
 Child entering at age 2-3  25 hours per week building to 40 hours  Emphasis on
• Building a relationship with child • Replacing challenging behaviors with functional communication
 Mands (Requests)  Tacts (labels)
Allocation of Hours
40 30 20 10 0 Year Year Year Year 1 2 3 4 S chool-based
• Receptive identification (objects, actions, body parts, colors, shapes) • Receptive instructions • Verbal and Non-verbal Imitation • Identical Matching • Play Skills (toy play) • Adaptive Skills (toilet training) • Fine and Gross Motor • Dietary restrictions/medical compliance
Hom e-based
A 4 year progression
Year 2:
 Child age 3-4  40 hours (in home with partial transition to school)
 Emphasis on
• Building Expressive Language
 Objects, Actions, Attributes, Prepositions, Pronouns  Categories, Functions, Occupations, Locations
Allocation of Hours
40 30 20 10 0
• Beginning Conversation
 Intraverbals  Reciprocal Statements  Asking Questions
• Developing Observational Learning
 I See  Sequences  Tell me about/Describe
Year Year Year Year 1 2 3 4 S chool-based
Hom e-based
• • • • • • •
Emotion Recognition Inferring others desires Play Skills (functional pretend, symbolic, imaginary) Adaptive Skills (dressing, grooming, feeding) Fine and Gross Motor Sharing and Turn taking Attention (dual and divided)
A 4 year progression
Year 3:
 Child age 4-5  40 hours (20 hours at home; 20 hours at school)  Sample Programs
• Advanced Language Concepts
 Pragmatic Language  Maintaining Conversation (topic initiation, repair, maintenance)
Allocation of Hours
40 30 20 10 0 Year Year Year Year 1 2 3 4 S chool-based
• Meta and Social Cognition
 Identifying and Managing own emotions  Understanding other’s Perspectives, Knowledge and Beliefs  Inferences
• Executive Function
    Attention Saliency Flexibility with Routines Inhibition and Self Monitoring Planning
Hom e-based
• Social Skills
 Levels of Friendship  Recognizing Social Cues
• • • •
Problem Solving Play Skills (peer play dates) Adaptive Skills Fine and Gross Motor
A 4 year progression
Year 4:
 Child age 5-6  40 hours (10 hours at home; 30 hours in school and fading services)  Emphasis on
• Teacher and Parent training • School Skills
 Listening and Reading comprehension  Math and Problem Solving
Allocation of Hours
40 30 20 10 0 Year Year Year Year 1 2 3 4 S chool-based
• Advanced Social Skills
 Detecting Sarcasm  Understanding Deception  Group Skills
Hom e-based
• Continued Self Regulation
 Self Esteem and Confidence  Task and Social Planning