ABAI CONFERENCE IN CHICAGO: WHAT HAVE WE LEARNT

As usual the conference was impressive and daunting, in fact too much so. Not only was there an abundance of options, all sounding good, but also the venue was vast. I had to be very strict in making choices and picked mainly keynote speakers, so here are some highlights, impressions and ideas to take away.

There was a lot about babies, how to diagnose them and how to work with them. This is something we at ISADD have been interested in. and I followed the theme, thus missing other topics.

We are on the right track at ISADD in pushing the diagnosis to be earlier and earlier. The literature now points out that we can reliably see differences in some, if not all infants, as early as 4 months, and with some babies, the suspicion can start earlier.  This is now so much simpler when we no longer are searching for a delay in language development, but are looking at the social precursors of communication. In Perth we have argued and succeeded for the acceptance of earlier diagnosis, but we still hear of parents being sent away to wait till the child is at least 3 years old.

We are also on the right track looking at developmental norms and noting how competent typical babies can be. A presentation by Pauline Flipek of the University of Texas pointed this out and gave a list of milestones.  Babies seek eye contact when breast feeding, and often even in the delivery room. By 10-12 weeks, early reciprocal conversation is there and baby adds sound to eye contact after listening to mother. This is done in real turn taking. Next comes imitation of mouth movements, and if mother’s face is not reflecting bub’s, bub is confused. By 4 months there is a response to name, by 6 to 7 gaze following, and babble is directed at people. By 10 months we have pointing, showing and sharing, and by 12months, following a pointing gesture and words can be taught. All this can sound very depressing when compared to some of our little clients, but that is not the way to look at it. These milestones reflect the early stages of both receptive and expressive communication. These milestones can give us exact targets to teach. Flipek went on to point out that at 6 months of age 10 hours weekly was enough to get results, with more input as the child gets older.

In working with babies, parents are the key players. Dr Tamis-Lemonda of New York University posed the question “infants make sense of chaotic input. How?” His answer was that bubs learn from a social environment and parental responsiveness promotes language. He quoted a study where babies were taught Mandarin, though it was not their home language. One group learnt with teachers and the other with a TV screen, following the same program. You can guess which group did better. (The former of course.) And here is the answer to all those who have been seeking a new app to teach their child to talk.  Parents were divided into two groups according to their responsiveness to their children, high responsiveness/interaction was defined by frequency and duration of interaction by touch, gesture and vocalisation. Also by number of words and when and how given; for example a label was to be given within 2 seconds of bub touching an item of interest, words used needed to be comments, and not just instructions. The children of the high group had words by 11 months, but the low group reached that level at 21 months. There was a big difference also in verbal memory.

This gives us strategies to teach parents of less responsive children. It is well known that parents may start off with the best of ‘motherese’ interaction, but a baby who does not respond does not encourage this and parents adapt. He concluded that tablets and Einstein baby DVD’s do not teach interaction, people are still needed. This goes for all babies but so much more for our group where the social basis of communication needs to be put together, skill by skill.

There was a session on methods of identification, and most of our behavioural information is based on retrospective studies, looking at old videos of diagnosed children and prospective studies, tracking the development of siblings who may eventually be diagnosed. There was reference to biomarkers, ‘anti brain’ antibodies found in mother’s placenta but this is still based on correlation, not causation, and the ethics of using this as a diagnosis seems dubious. There is also a big error margin, and just relying on parental concern has a similar accuracy rate. I liked Dr G. Novak of California State University explaining Autism in systems theory as a neuro–developmental disorder, where we know very little about the neurology, but the development is well defined in behavioural terms. In summary ASD is the result of degree of impairment in the organism multiplied by degree of unsupportive environment. I liked his final comment that potential skills do not emerge if they are not needed. I like this statement as it points out  what our programs need to do – set up need situations to make the child make requests, make the child more independent, make the child see the value of social interaction.

There were a number of good papers on managing verbal stims and none of them had an easy solution, other than interrupting and rewarding the opposite behaviour.  It is a difficult task and there is no magic, as the child finds this behaviour more rewarding than much of what we have to offer. A high level of social interaction during a teaching session also helped reduced self stimulation levels. Certainly pressure vests, though expensive, do not work when data is taken with precision (and the presenter now has four second hand vests to sell on e-bay).

There were papers on reinforcement and on modelling as a form of teaching. But we may talk about these later.

Last but not least I was impressed by a paper by Jesus Rosales-Ruiz of the University of North Texas. He pointed out that we tend to look at the Discriminative Stimulus (Sd) as a discrete entity and an instruction we give, but to a child the total situation, the environment and all present at the time including the child’s own reactions will become amalgamated into one confusing Sd. This is a very plausible explanation for the reluctance and fear of failure we see in children when we know they can achieve. What experiences are they remembering in association with the simple task we present? This is the most powerful argument for errorless learning and time delayed prompting possible. It also suggests that hand over hand prompting, which can be quite aversive to a child with ASD, is not a good teaching tool. How did we get that child to the therapy session and to the table on the first occasion? Maybe taking more time and waiting for the child to come independently, enticing the child into a closer interaction is a better way and will save much time later. This is going to be central to our training of therapists in the future.

Jura Tender