Behavior Analysis & Autism - by Paul Coyne PhD

Using Pivotal Response Teaching (PRT) to Teach Language

via vimeo.com

Tina filmed, edited and stars in this nifty little video clip we made on how to use pivotal response teaching to teach language skills. The password is coynemovies .  Paul Coyne and Tina Cavallaro.

Psychotropic Medication and Children

October 2, 2010

 

Side Effects May Include Lawsuit

By DUFF WILSON

 

FOR decades, antipsychotic drugs were a niche product. Today, they’re the top-selling class of pharmaceuticals in America, generating annual revenue of about $14.6 billion and surpassing sales of even blockbusters like heart-protective statins.

While the effectiveness of antipsychotic drugs in some patients remains a matter of great debate, how these drugs became so ubiquitous and profitable is not. Big Pharma got behind them in the 1990s, when they were still seen as treatments for the most serious mental illnesses, like hallucinatory schizophrenia, and recast them for much broader uses, according to previously confidential industry documents that have been produced in a variety of court cases.

Anointed with names like Abilify and Geodon, the drugs were given to a broad swath of patients, from preschoolers to octogenarians. Today, more than a half-million youths take antipsychotic drugs, and fully one-quarter of nursing-home residents have used them. Yet recent government warnings say the drugs may be fatal to some older patients and have unknown effects on children.

The new generation of antipsychotics has also become the single biggest target of the False Claims Act, a federal law once largely aimed at fraud among military contractors. Every major company selling the drugs — Bristol-Myers Squibb, Eli Lilly, Pfizer, AstraZeneca and Johnson & Johnson — has either settled recent government cases for hundreds of millions of dollars or is currently under investigation for possible health care fraud.

Two of the settlements, involving charges of illegal marketing, set records last year for the largest criminal fines ever imposed on corporations. One involved Eli Lilly’s antipsychotic, Zyprexa; the other involved a guilty plea for Pfizer’s marketing of a pain pill, Bextra. In the Bextra case, the government also charged Pfizer with illegally marketing another antipsychotic, Geodon; Pfizer settled that part of the claim for $301 million, without admitting any wrongdoing.

The companies all say their antipsychotics are safe and effective in treating the conditions for which the Food and Drug Administration has approved them — mostly, schizophrenia and bipolar mania — and say they adhere to tight ethical guidelines in sales practices. The drug makers also say that there is a large population of patients who still haven’t taken the drugs but could benefit from them.

AstraZeneca, which markets Seroquel, the top-selling antipsychotic since 2005, says it developed such drugs because they have fewer side effects than older versions.

“It’s a drug that’s been studied in multiple clinical trials in various indications,” says Dr. Howard Hutchinson, AstraZeneca’s chief medical officer. “Getting these patients to be functioning members of society has a tremendous benefit in terms of their overall well-being and how they look at themselves, and to get that benefit, the patients are willing to accept some level of side effects.”

The industry continues to market antipsychotics aggressively, leading analysts to question how drugs approved by the Food and Drug Administration for about 1 percent of the population have become the pharmaceutical industry’s biggest sellers — despite recent crackdowns.

Some say the answer to that question isn’t complicated.

“It’s the money,” says Dr. Jerome L. Avorn, a Harvard medical professor and researcher. “When you’re selling $1 billion a year or more of a drug, it’s very tempting for a company to just ignore the traffic ticket and keep speeding.”

NEUROLEPTIC drugs — now known as antipsychotics — were first developed in the 1950s for use in anesthesia and then as powerful sedatives for patients with schizophrenia and other severe psychotic disorders, who previously might have received surgical lobotomies.

But patients often stopped taking those drugs, like Thorazine and Haldol, because they could cause a range ofinvoluntary body movements, tics and restlessness.

A second generation of drugs, called atypical antipsychotics, was introduced in the ’90s and sold to doctors more broadly, on the basis that they were safer than the old ones — an assertion that regulators and researchers are continuing to review because the newer drugs appear to cause a range of other side effects, even if they cause fewer tics.

Contentions that the new drugs are superior have been “greatly exaggerated,” says Dr. Jeffrey A. Lieberman, chairman of the psychiatry department at Columbia University. Such assertions, he says, “may have been encouraged by an overly expectant community of clinicians and patients eager to believe in the power of new medications.”

“At the same time,” he adds, “the aggressive marketing of these drugs may have contributed to this enhanced perception of their effectiveness in the absence of empirical evidence.”

Others agree. “They sold the story they’re more safe, when they aren’t,” says Robert Whitaker, a journalist who has written two books about psychiatric medicines. “They had to cover up the problems. Right from the start, we got this false story.”

The drug companies say all the possible side effects are fully disclosed to the F.D.A., doctors and patients. Side effects like drowsiness, nausea, weight gain, involuntary body movements and links to diabetes are listed on the label. The companies say they have a generally safe record in treating a difficult disease and are fighting lawsuits in which some patients claim harm.

The cases, both civil and criminal, against many of the world’s largest drug makers have unveiled hundreds of previously confidential documents showing that some company officials were aware they were using questionable tactics when they marketed these powerful, expensive drugs.

Such marketing, according to analysts and court documents, included payments, gifts, meals and trips for doctors, biased studies, ghostwritten medical journal articles, promotional conference appearances, and payments for postgraduate medical education that encourages a pro-drug outlook among doctors. All of these are tools that federal investigators say companies have used to exaggerate benefits, play down risks and promote off-label uses, meaning those the F.D.A. hasn’t approved.

Lawyers suing AstraZeneca say documents they have unearthed show that the company tried to hide the risks of diabetes and weight gain associated with the new drugs. Positive studies were hyped, the documents show; negative ones were filed away.

According to company e-mails unsealed in civil lawsuits, AstraZeneca “buried” — a manager’s term — a 1997 study showing that users of Seroquel, then a new antipsychotic, gained 11 pounds a year, while the company publicized a study that asserted they lost weight. Company e-mail messages also refer to doing a “great smoke-and-mirrors job” on an unfavorable study.

“The larger issue is how do we face the outside world when they begin to criticize us for suppressing data,” John Tumas, then AstraZeneca’s publications manager, wrote in a 1999 e-mail. “We must find a way to diminish the negative findings,” he added. “But, in my opinion, we cannot hide them.”

Tony Jewell, an AstraZeneca spokesman, said last week that the company had turned over all that material to the F.D.A. as part of the approval process and updated its label over the years to show the latest safety information.

Dr. Stefan P. Kruszewski, a Harvard-educated psychiatrist who once worked as a paid speaker for several drug makers, became a government informant and now consults for plaintiffs suing drug companies. Earlier in his career, he spoke at events for Pfizer, GlaxoSmithKline and Johnson & Johnson as an advocate of antipsychotics. He said one company offered him incentives of $1,000 or more every time he talked to an individual doctor about one of its drugs.

“When I started speaking for companies in the late 1980s and early ’90s, I was allowed to say what I thought I should say consistent with the science,” he recalls. “Then it got to the point where I was no longer allowed to do that. I was given slides and told, ‘We’ll give you a thousand dollars if you say this for a half-hour.’ And I said: ‘I can’t say that. It isn’t true.’ ”

Slides for one new antipsychotic drug contended that it had no neurological side effects. “They made it all up,” Dr. Kruszewski said. “It was never true.”

The antipsychotics found an easy route around regulations because of the leeway given to many big drug makers.

While drug companies are prohibited from promoting drugs for conditions for which they have not been proved safe and effective, their paid consultants, researchers and educators may do that for them verbally and in company-sponsored studies.

“They can give a small hint, and people will take the bait,” says Dr. Robert Rosenheck, a professor of psychiatry and public health at the Yale School of Medicine, who has received research support from drug makers and federal agencies. “Psychiatric disorders are vaguely defined enough that you can stretch definitions,” he says. “So many treatments are completely ineffective, people are willing to try anything.”

For their part, doctors are free to prescribe any approved drug for any medical condition they choose, even if the drug hasn’t been approved for that specific treatment. “Because they’re approved, they become an alternative for doctors who can’t think of what else to prescribe,” says Dr. Daniel J. Carlat, an associate professor of psychiatry at Tufts University. “Whether they’re useful or not is unclear.”

Analysts said that given the profits that were to be made, the murkiness of mental disorders, and holes in the regulatory regime, marketing excesses were bound to occur.

“If you have a lot of money on the table and you have clinical uncertainty over mental health conditions, where you don’t have a blood test or objective test for it, you see it’s kind of a combustible mixture,” says Dr. Mark Olfson, a Columbia University psychiatry professor and researcher.

DOCUMENTS produced in recent litigation and in Congressional investigations show that some leading academic doctors have worked closely with corporate benefactors to expand the use of antipsychotics.

The most well-known is Joseph Biederman, a Harvard medical professor and Massachusetts General Hospitalresearcher. His studies, examining prevalence of bipolar psychological disorders in children, helped expand practice standards, leading to a fortyfold increase in such diagnoses from 1994 to 2003. The increase was reported in a 2007 study by the Archives of General Psychiatry.

Between 2000 and 2007, he also got $1.6 million in speaking and consulting fees — some of them undisclosed to Harvard — from companies including makers of antipsychotic drugs prescribed for some children who might have bipolar disorder, a Senate investigation found in 2008.

Johnson & Johnson gave more than $700,000 to a research center that was headed by Dr. Biederman from 2002 to 2005, records show, and some of its work supported the company’s antipsychotic drug, Risperdal.

Dr. Biederman says that the money did not influence him and that some of his work supported other drugs.

“Dr. Biederman’s research does not promote a particular diagnosis or treatment,” his lawyer, Peter Spivack, wrote in an e-mail on Thursday.

The increase in pediatric bipolar diagnosis, the lawyer said, “cannot be attributed solely to Dr. Biederman’s work.” Treatment was expanded to help children and their families, he said.

Mr. Spivack said Dr. Biederman’s disclosure lapses were minor and inadvertent. A Harvard spokesman said they were still under review.

According to government investigators and plaintiffs’ lawyers, many of the studies of antipsychotics were conceived in marketing departments of pharmaceutical companies, written by ghostwriters and then signed by prominent physicians — giving the illusion that the doctors were undertaking their studies independently.

Such practices continue.

“The content is preplanned,” said one doctor who has worked as an uncredited medical writer for antipsychotic studies. Data is used selectively and interpreted for company benefit, said the doctor, who still works in medical writing and spoke on the condition of anonymity to preserve future job prospects.

“Review articles and original research articles have advertising messages in them,” the doctor said. “That’s part of the plan.”

Such papers influence medicine in many ways, as sales representatives show them to doctors and future research builds upon them.

ACCORDING to the Justice Department, drug companies trained sales reps to rebut valid medical concerns about unproved uses of antipsychotics. For example, the department says, Lilly produced a video called “The Myth of Diabetes” to sell Zyprexa, which became its all-time best-selling drug, even though evidence showed that Zyprexa could cause diabetes, as well as other metabolic problems.

Lilly salespeople also promoted a “5 at 5” drug regimen in nursing homes — 5 milligrams of Zyprexa at 5 p.m. to settle down agitated older patients for the night. A Lilly spokesman declined to say when those sales campaigns occurred. But in 2005, after a new analysis of 15 previous studies, the F.D.A. issued a public health advisory saying the use of antipsychotics to calm older dementia patients would increase risk of death from heart failure or pneumonia. The F.D.A. asked drug makers to add a special warning about that on packaging.

Over the years, as psychiatrists learned more about the drugs’ risks, companies promoted them more to family doctors, pediatricians and geriatricians. Pfizer paid more than 250 child psychiatrists to promote its antipsychotic, Geodon, at a time when it was approved only for adults, according to a government filing with the Pfizer settlement last year.

High-prescribing doctors pocketed extra money in the form of research payments, speaking fees, gifts, meals and junkets — some of which the government has specifically termed illegal “kickbacks.”

In its suit against AstraZeneca, the government produced documents showing that the company paid a Chicago psychiatrist, Dr. Michael Reinstein, nearly $500,000 over a decade to do research, travel and speak for it — even as he led a Medicaid practice he had described to the company as one of “the largest prescribers of Seroquel in the world.”

Dr. Reinstein and AstraZeneca have both denied any misconduct.

In April, AstraZeneca became the fourth major drug company in three years to settle a government investigation with a hefty payment — in its case, $520 million for what federal officials described as an array of illegal promotions of antipsychotics for children, the elderly, veterans and prisoners. Still, the payment amounted to just 2.4 percent of the $21.6 billion AstraZeneca made on Seroquel sales from 1997 to 2009.

LAST year, Eli Lilly and Pfizer settled investigations resulting in the largest criminal fines in United States history. Lilly paid a $515 million criminal fine as part of a broader, $1.4 billion settlement with the government. Pfizer later paid a $1.3 billion criminal fine as part of a broader, $2.3 billion settlement.

The Lilly case focused entirely on its antipsychotic drug Zyprexa, while Pfizer’s settlement included $301 million related to its antipsychotic, Geodon, along with marketing of other drugs.

In 2007, Bristol-Myers Squibb paid $515 million to settle federal and state investigations into marketing of its antipsychotic drug Abilify to child psychiatrists and nursing homes. Bristol-Myers Squibb, like AstraZeneca, denied any misconduct.

Johnson & Johnson is currently under investigation by the Justice Department, which says it paid kickbacks to induceOmnicare, the nation’s largest nursing home pharmacy, to recommend Risperdal, government filings show. Omnicare paid $98 million last November to settle civil charges.

J.& J. is fighting a government lawsuit and says in court filings that it was paying rebates — an argument endorsed in a filing by the industry trade group, the Pharmaceutical Research and Manufacturers of America.

Some officials at companies say they’ve made systemic changes to avoid illegal marketing of antipsychotics and other products.

“That was a blemish for us,” John C. Lechleiter, Eli Lilly’s chief executive, said in an interview. “We don’t ever want that to happen again. We put measures in place to assure that not only do we have the right intentions in integrity and compliance, but we have systems in place to support that.”

Jeffrey B. Kindler, Pfizer’s chief executive, voiced similar thoughts in an interview. “Never again,” he said. “I take this very seriously.”

Mr. Kindler is operating under Pfizer’s third corporate accountability agreement, a five-year promise to the federal government to reform sales behavior, monitor employees and disclose misconduct. The first was signed in 2002 for withholding rebates for Lipitor. The second, in 2004, was for illegal marketing of the seizure drug Neurontin. The third, last year, was for illegal marketing of the painkiller Bextra.

Pfizer officials say they inherited the first two situations with their acquisitions of two other companies, Warner-Lambert and Parke-Davis.

“It wasn’t our people,” says Douglas Lankler, a senior vice president and chief compliance officer at Pfizer.

Lew Morris, chief counsel for the inspector general of the Department of Health and Human Services, says he is serious about bolstering government efforts to reform or punish drug makers for illegal sales of antipsychotics.

“The message we want to send to the industry is it’s not just the same-old, same-old,” he said in an interview.

He agrees that few industry employees have gone to jail for white-collar crimes, but says this may change soon. “We’re targeting managers and executives who should have known,” he said.

Mr. Morris says some companies are “too big to debar” from government contracts, since doing so would just hurt patients needing medicine. But he says discussions are under way about forcing one health care company to sell off a subsidiary accused of fraud. And directors who ignore information may face more risk of shareholder suits, he says.

Over the next year, the government is adding at least 15 prosecutors and 100 investigators to pursue health care fraud.

The Pharmaceutical Research and Manufacturers of America, also strengthened its marketing code of conduct two years ago, banning gifts and meals, although salespeople can still bring meals to doctors’ offices.

Some companies are also disclosing their consulting and speaking payments, as required by the government agreements. And groups in charge of medical writing and postgraduate education have taken steps to disclose or reduce industry influence.

But more than 1,000 False Claims Act lawsuits are still under way, most of them focused on health care and many on lucrative antipsychotic drugs. For that reason alone, critics say they think the industry still hasn’t gone far enough to change questionable practices.

“The drug industry still rewards sales,” says Stephen A. Sheller, a lawyer who has represented whistle-blowers in the Lilly and AstraZeneca cases. “And it’s still easy to market these drugs to doctors who are rushed.”

 

 

Helping autistic children with iOS devices [From the TUAW blog]

Filed under: Education

Helping autistic children with iOS devices

by David Winograd (RSS feed) on Aug 18th 2010 at 2:00PM

Autism is a developmental brain disorder that, in some manner, plagues one out of every 110 children (according to the Centers for Disease Control). It's usually discovered by the time the child is three years old. Varying medical and scientific authorities characterize the condition in different ways, but scientists generally agree that autism spectrum disorders (ASD) manifest themselves in social, communication, and behavioral challenges. The SF Weekly recently wrote about a number of families with autistic children and how the iPad is proving to be quite useful in helping them.

A number of studies have been done on the use of iPhones and iPods as aids for the autistic. One such study was titled iPod Therefore I Can: Enhancing the Learning of Children with Intellectual Disabilities Through Emerging Technologies, and it tracked the progress of 10 autistic children who were using iPod touches in Australia.

The results were quite encouraging. In one case, a child who could not wash his hands was exposed to photos (combined with voice-overs) of a child doing it successfully. Through this method, the correct behavior was reinforced, and in short order, the child was able to wash his hands by himself. About 60 percent of the goals of the study were achieved.

The results of this and other studies have been encouraging, but a major problem for 60 to 80 percent of autistic children is poor motor skills, including poor motor planning, which makes using the small buttons on an iPhone or iPod touch quite difficult. Because of the larger size of an iPad, it can be much more accessible to a larger number of autistic children.

The first major study concerning autism and the iPad (titled Touch Technologies in the Classroom) is currently underway in Toronto. In February, iPads and and iPod touches were installed in six classrooms where they could be used by autistic children. The data is still being analyzed, but the results seem to be positive and indicate that the use of these devices can extend short attention spans, demonstrate understanding, and increase interest (at least in playing with the iPad) when students were previously found to have scant interest in much of anything. One major problem with the use of the iPad is that it is quite fragile, and a good number of autistic children are prone to violent outbursts. One big tantrum could easily result in a shattered iPad.

A large number of apps have been introduced to assist the autistic, and they seem to fall into three categories: those that help with attention span, those that help with communication, and those that help with organization.

Short attention spans are found in the the majority of children with ASD, and this can be a major problem in public if the child gets bored and acts out. One app that seemed to help isiEarnedThat (US$1.99). This app allows parents to use pictures (or take one if they're using an iPhone) for creating jigsaw puzzles with varying numbers of pieces and is compatible with iPhone, iPod touch and iPad. Next, the parent determines a reward. The general idea is that each time a child completes a positive task, they get to put a piece in the puzzle, which when finished, reinforces the behavior, and the child will get the reward. 

One parent of an autistic child used it in a simpler manner, though. In an airport, after finding out that their flight would be delayed, her son started to act out. She used iEarnedThat to create a 30-piece puzzle, which occupied her son for the next half-hour. (He was used to doing 15 piece puzzles.) The reward was cookies. This may not seem like much, but it averted a crisis and taught the parent that her child could be occupied for longer than she ever imagined. 

For children who need to master simple organizational skills in a particular sequence (for example, find toothbrush, find toothpaste, take the cap off, wet toothbrush, brush teeth, etc.), there are a few apps that can help. One is First Then Visual Schedule (US$13.99). This app is also compatible with multiple devices, and it uses pictures and voice recordings to build a lock-step sequence that can be repeated. Another app is Stories2Learn (US$13.99), and it's also not iPad specific. This app is used to create social stories that will show the child how to behave in certain situations. Using an iPhone, photos of the child demonstrating the correct behavior can be sequenced into stories that use text, photos, and recorded sounds. This app has been used to model how to behave at the dinner table, or it could be used to set up sequential tasks in a narrative format. I haven't had a chance to use either of these apps, but they both provide context and motivation, which are critical for success. 

We've covered a few augmentative and alternative communication (AAC) apps, which allow non-communicative children to make their intentions known. Proloquo2Go (US$189.99) is the most extensive of these apps. It's enhanced for the iPad, and it allows the building of phrases through the use of customizable buttons. As is the case with other AAC apps, the price is absurdly low when compared to the non iPad/iPhone competition of standalone devices that can cost anywhere from $3,000-$8,000. A much simpler (and cheaper) app is the AutoVerbal Talking Soundboard(US$8.99). This iPad-enhanced app allows for the customization of one row of buttons. You can choose from hundreds of preset buttons that speak one phrase when touched. Another limited feature app is iConverse (US$9.99), and it's not iPad enhanced. This is geared for low functioning autistic children, and it allows them to use six buttons to display common needs, including bathroom, eat, drink, sick, break, and help. The current version allows voice recording to customize the six graphics. 

These examples are harbingers of more and better apps to come. Compared to something like games, the market is quite small, and the research that drives such apps is slow to filter down to a product development stage. Given that, I would expect to see a slow but constant trickle ofAssistive Technology apps being released. 

Matthew Goodwin, Director of Clinical Research at the MIT Media Lab, is planning to launch a major project that studies what "sexy" technologies (like the iPad) can do for the autistic. He doesn't see the iPad as the perfect device, but he says that "it is currently a very appealing system given its size, rich screen display and processing power." Goodwin believes that the technology can potentially make the lives of the autistic easier. However, if they're successful, they may be able to do something that's just as important: demonstrate to society the hidden potential in children with autism.

via www.tuaw.com

What to Do if You Suspect a Learning Disability: A Critique

Paul Coyne PhD

The New York Times published an article, “What to Do if You Suspect Learning Disability by Lesley Alderman on February 19 2010.  The article provided advice about what to do if a parent suspects his or her child has a learning disability.  She describes how a parent might obtain services for their child with special needs through the local school district.  Ms. Alderman provided some good advice and some incorrect advice.  Since the issues raised are common among parents who have children with autism, I thought I’d comment on her article here. 

Ms. Alderman writes:

    “The first sign may be that your bright child is having trouble reading or organizing school assignments, or concentrating on homework.  Your child may be frustrated with school, and you may find yourself frustrated with what looks like a lack of effort.  And a teacher may also notice that something is amiss.” 

The description suggests that the child does not have the prerequisite skills to complete the academic assignments.  His or her language skills, reading skills or arithmetic skills may be below grade level.  The teaching techniques, the curriculum, the motivational system used, or a combination of all three were not effective teaching the child the skills s/he needs to be successful. 

Ms. Alderman suggests ‘your best recourse is to have the child tested’.  I agree.  An essential key to learning is to assess the child’s skills and place the child in the appropriate place in the curriculum.  However, be careful of labels. If a child is in fourth grade, but his reading level is at the second grade level, labeling the child, that is, identifying the child as having a learning disability does not explain why the child is two grade levels behind. A diagnostic label is not an explanation. As mentioned above, it could be the teaching techniques, the curriculum, some aspect of the environment that is responsible for his rate of learning, not necessarily a neurological problem. 

Nevertheless, an educational assessment and/or a behavioral assessment of your child’s performance at school is recommended.  Ms. Alderman points out that you may request a free assessment from your local school district. The results of the assessment will be discussed at an Individual Educational Program (IEP) meeting. The district will discuss if your child is eligible for special education services.  If your child was determined to be eligible previously, the IEP team will suggest relevant goals and objectives and discuss services your child may require to make progress towards the goals and objectives.   If you are dissatisfied with that assessment you may ask for a second opinion.  The district may offer another professional to provide the second opinion.  However, you may have an independent professional do an assessment.  

Once the independent assessment is completed request a new IEP by writing to the Director of Special Education.  You do not have to wait for your child’s annual review.  You can request an IEP anytime.  Ask the independent examiner (e.g., Behavior Analyst, Psychologist, Speech & Language Pathologist) to come to the IEP meeting to discuss his or her results and to suggest goals and objectives for the IEP.  The assessor may also recommend an intervention program.  S/he may recommend specific changes in the curriculum, or may recommend using particular reinforcers to improve motivation or recommend remedial instruction from a specially trained teacher.   

If goals and objectives to the IEP are added as a result of the independent assessment you can submit the cost of the assessment to the school district for reimbursement. If the school district denies your request, appeal the decision.  If the school district does not agree to the goals and objectives or to the services recommended by the independent examiner, do not request a hearing with the board of education as Ms. Alderman suggests. Instead, file for due process by writing to the Director of Special Education. Try to resolve your disagreement by scheduling a mediation conference.  You may not obtain all the services requested.  However, you may be able to work out an acceptable compromise. If not you can take your case to a fair hearing (sometimes called a due process hearing) where your case will be heard by a judge.  Whether you participate in a mediation conference or in a due process hearing it is wise to bring an attorney or someone knowledgeable about the special education code to represent you. 

Outcome Data From ABA Early Intervention Program, 2009

Coyne & Associates Education Corporation

Progress Report

April 2009

Paul Coyne 

Mary Alice Coyne

Len Levin

Christina Cavallaro

Coyne & Associates provides an infant development program serving children with autism and other developmental disabilities. Most of the children referred to Coyne & Associates are on the autism spectrum.  Other children are on the autism spectrum and also have some measure of mental retardation. Coyne & Associates sends teachers into each child’s home to  provide a program of instruction designed to influence the child’s development such that he or she acquires the skills found in typical children of the same age.  Each week a supervisor observes the teacher work with the child in the home, monitors the child’s progress, makes changes to the program when necessary, meets with the parent and provides parent training. The program of instruction is designed to improve a child’s areas of deficit and areas of strength.  Instruction is provided across a variety of skill areas which include: gross motor skills, fine motor skills, self help skills, speech and language skills, general knowledge and comprehension, social and emotional development, plus cognitive skills.  The teachers use teaching techniques based on applied behavior analysis.  Some of the teaching is structured (discrete trial teaching, independent activity schedules), some of the teaching is naturalistic (pivotal response teaching, incidental teaching).  It is common for children to receive 10 hours of 1:1 instruction each week with and additional 2 hours of  supervision.  As the child progresses the number of hours of instruction generally increases.  Some children receive less..  Each program is individualized according to the child’s needs, the parent’s consents, and the input from the interdisciplinary team.  This past year we were fortunate to have the consultative services of a speech pathologist.  This year (2009) we added the services of an occupational therapist.

The current report reflects data obtained from 1/1/06 to 12/31/08. Three years of data were used to ensure enough children in each category so conclusions about outcomes could be made.  Each child was tested using the Brigance Diagnostic Inventory of Early Development II, by Albert Brigance (2004).  The data are grouped in two ways.  The first is by the number of months that the clients were enrolled in the program and the second is by the total number of hours of services that the clients received while enrolled in the program.  In previous years our progress reports displayed the results of children with and without profound or severe mental retardation separately.  This report reflects the data obtained from all children combined with one exception noted below. 

 

 Generally, within each skill area, more improvement was seen as the amount of time in the program increased.  Also, the greater the number of hours of instruction a child received the more progress the child made. 

The following tables show the number of clients within each month or hour bracket.

Time In Program	3 Months	6 Months	9 Months	12 Months	15 Months	15+ Months
Number of Clients	44	91	98	52	35	12

Total Hours Received	375 Hours	750 Hours	1125 Hours	1125+Hours	1125+ Hours **
Number of Clients	187	115	24	6	3

**In the bracket of 1125+ hours there were nine children (light blue). Six children had a level of functioning that placed them in the category of severe, profound, or moderate mental retardation. Three children had mild mental retardation or borderline intellectual functioning . Their Brigance scores were presented separately only in the speech and language skill area. 

The more instructional hours provided, the greater the gains received.  The overall category averages the gains obtained across all skill areas.  Children tended to make more than 10 months of developmental gain when they received 1124 hours of instruction or more.  The greatest gains were obtained when children received more than 1125 hours of instruction.  Close to 20 months of gains were obtained in general knowledge and comprehension, and 16.5 months of gains overall were obtained when more than 1125 hours of instruction were provided.  The majority of the children in the Coyne program received 750 hours of instruction or less. They tended to make 6-8 months of developmental gains.  They tended to make more improvement in social and emotional development and language development. That is their behavior problems improved and they were more able to make their wants and needs known to others. 

Similar results were seen when progress was viewed as a function of  the amount of time a child spent in the program. After 3 months in the program children made approximately 6 months of progress or more in fine motor, speech and language, knowledge/comprehension and social emotional development.  That is, 2 months of progress developmentally were obtained for every month in the program. That rate of progress decreased from 3 to 9 months.  After 9 months in the program the average child made slightly more than 1 month of developmental progress for every month in the program. 

Children made almost 12 months of developmental progress after participating more than 15 months.  Social Emotional development increased by 10 months after 12 months in the program. Knowledge / comprehension increased by 14.5 months when a child was enrolled for more than 15 months.  

All children exit the program on their third birthday. The earlier a child entered the program and the more instructional hours received the more progress a child attained.  Children had the fastest rate of learning when they were 32-36 months old.  Then the rate of learning was two months developmentally for every month in the program.  

This fast rate of learning during the first three months of the program may be more of a reflection of the measurement instrument and the initial goals addressed rather than an actual ‘rate of learning’ measurement.  Some basic skills were acquired relatively quickly: better eye contact; following routine instructions; making simple requests by pointing; functional play and task completion skills.  Those skills were acquired in the first three months and had a significant impact on the child’s Brigance levels.  Subsequently, the more intermediate programs were introduced. The intermediate programs developed visual and auditory discrimination / listner repitoires, more sophisticated imitation, social play, conversation skills and so on.  It may take longer for progress to occur in those areas where the prerequisite skills are being mastered, which would make it look like the ‘rate of learning’ slows.  However, that may be the result of the scope and sequence of the curriculum.  Once a certain level of prerequisite skills were mastered other skills were learned at a faster rate.  That may be why our program saw more significant benefit early in training, a plateau and then another spurt of skill building. ¹  In our view,  there is an advantage to introducing programs sequentially versus hitting the children with many programs at once. 

To obtain a rate of progress such that a child’s developmental level increased near or faster than their chronological age, children received approximately a cumulative total of  750-1124 or more  hours of instruction or they participated in the program longer than 9 months. Most children who participated in the program longer than 9 months received 54 hours a month at the beginning of their program.  They may have gradually moved up to 18 or 20 hours a month by the time 9 months had passed.  If  we say the average child received 18 hours a week over 9 months, that is only 702 total hours.  The data graphed hourly indicates that 750-1124 hours are needed to obtain learning rate that approximates or exceeds 1 month of developmental increase for 1 month in the program.  This would suggest that time in the program is a more important factor than hours recieved, that is, it is better to receive 1124 hours of instruction over a longer period of time than a shorter period.  However, since these results do not meet the true rigor of science, we are unable to answer what is more important, the number of hours received or the amount of time in the program. 

__________________

[Footnote 1. This ‘S’ curve model of learning was seen also when we analysed our data from 2004 – 2006 ( Coyne, P., Probst, J., Levin, L, and Coyne, M. Outcome data from an early intervention program. Paper presented at the 34^th Annual Convention of the Association for Behavior Analysis International 2008)]

The results of our Parent Satisfaction Survey taken in 2009 were as follows:

Coyne & Associates Education Corporation

Parent Satisfaction Survey

 February 2009

San Diego County

Supervisors Early Childhood Interventionist (ECI)

Work Habits       3.80 Work Habits 3.71

Professionalism       3.82 Professionalism  3.75

Program Goals           3.05   Program Goals   3.77   

Parent Training       3.45 Parent Training 3.60

Scheduling       3.36 Scheduling 3.66

Assessment of child         3.75

Transition to school          3.80 

Child’s overall progress  3.65 

Orange County

Supervisors Early Childhood Interventionist

Work Habits                  3.82 Work Habits         3.82

Professionalism       3.95 Professionalism 3.77       Program Goals             3.25 Program Goals        3.70

Parent Training         3.49 Parent Training   3.50

Scheduling         3.50 Scheduling 3.60

Assessment of child         3.70

Transition to school          3.90 

Child’s overall progress  3.50 

Inland County

Supervisors Early Childhood Interventionist

Work Habits       3.92 Work Habits         3.91 

Professionalism       3.95 Professionalism         3.88

Program Goals            3.57  Program Goals         3.83 

Parent Training       3.46 Parent Training         3.56

Scheduling       3.48 Scheduling         3.79

Assessment of child       3.75

Transition to School       4.00

Child’s overall progress  3.76

Scale: 1 = Poor    2 = Fair   3 = Good   4 = Excellent  

Total Responses = 49  Mean time in the Program = 12.3 months

Supervisor’s program goals represents eight different categories.  Since the mean was masking the variability of the data, I summarized the individual scores per category since I thought the information looked interesting.  

For all three counties:

Does the program meet your child’s needs: 3.66

How would your rate your child’s progress in:

Social Skills:  2.97

Language: 3.15

Play Skills: 3.21

Cognitive Skills: 3.23

Following Instructions: 3.25

Imitation:  3.32

Parents were asked to complete a questionnaire rating the Supervisors and Teachers (ECIs) on a variety of work related behaviors.  A score of less than 2 was poor, a score greater than 3 was good to excellent. Almost all the scores were greater than 3.5. Parents rated their child’s transition to public school the greatest at 4.0. Program goals, parent training and scheduling, obtained good scores whereas work related areas received good to excellent scores.  Parents were good at rating their child’s success.  Their ratings matched the outcome scores on the Brigance reasonably well. Overall, parents were pleased with the progress their children made and pleased with the staff of Coyne & Associates. 

Download the Vaccination and Autism Study from the New England Journal of Medicine

Download vaccination_and_autism.pdf

A parent writes:

Dr. Coyne-
I wanted to take a moment to express to you our satisfaction with the
services we have received from your company. Upon my son Max's diagnosis of
PDDNOS (he has recently been diagnosed with Autism) when he was 19 months
old, we were set up by Regional Center to receive services from your
company. I honestly thank God that we were connected to your company.

I have the utmost respect and genuine affection for our supervisor Lauren.
Max's life has been forever changed because of her dedication to his
progress and her ongoing desire to connect with and understand him. She has
respected my every question, comment, or concern and has always been willing
to spend extra time helping me understand his progress or difficulties with
specific programs.

In addition, we have just undergone the IEP process with our local school
district and Lauren was absolutely integral to our achieving appropriate
goals and placement for our son. Her final report and the goals she
developed for Max to pursue in a school program were comprehensive and her
attention to detail and consideration of Max's strengths and weaknesses was
without fault. Her conduct at our IEP meetings was supportive of our family
and professional at all times.

In addition to Lauren, Len Levin also met with our family at our home, and
attended two of our IEP meetings. We are so thankful to Len for his guidance
and input regarding our son's program and for his presence at the IEP
meetings he attended. In our opinion, Len went above and beyond the call of
duty and we are forever grateful.

Lastly, as the mother of an autistic child whose future is largely ahead of
him and certainly a great unknown, it has given me peace of mind to have
Coyne and Associates provide Max's ABA Therapy in these crucial years. He
has made amazing progress and as I said will be forever changed as a result
of the dedication and commitment of your staff.

Sincerely,
A. R.

Max's Mom

A nice letter from a parent in our ABA Early Intervention Program

February 28, 2008
Dr. Coyne,

Hi! My name is Michelle and my son who is a client of yours is M. I know that in this world, people usually only hear from clients when there is a problem (which I have no problem addressing J), but I truly believe it is equally important to sing praises when deserved also!!! We are so excited about our little guy right now and I felt it was important to share that with you!

We have 5 kids and M is our youngest of our two sets of twins. Last summer, M was diagnosed with autism and our world turned upside down. VERY lucky for us, we were assigned to Coyne for our home ABA. You need to understand, at that time M had NO eye contact, zoned out completely for long periods of time and his entire existence consisted of lining trains up in a row or pushing a swing back and forth. He couldn’t tolerate even being in the same room with his brothers and sister due to the commotion. I was completely overwhelmed and did not have the faintest clue how to help him. In the midst of all this, Lauren, Michelle and Josh came in. I cannot say enough of how I feel regarding Josh and Michelle. Not only did Mark respond to them and consistently improve from Day 1, they ALWAYS made time to explain things to me and tell me what I and my husband could be doing to help M and stay consistent with their program also. Lauren came in, and has truly been a God-send to my entire family!!!! M has always responded to her, she is NEVER too busy to address any concern I have had or question – even if it’s outside of a typical work day hour. She has so much incredible knowledge and heart!!!!! I fully believe that M and my family would not have gotten through the past 8 months without her supervision, guidance and care!!!!!!!!!!!

Michelle and Josh left and for a myriad of reasons, M began regressing. It was a very worrisome time. But M wasn’t alone. Once again, Lauren was there and now with the equally amazing team of LeAnne and Susan. Jessica – whom I am also grateful to – also came out and together they were able to get Mark back on the right path again!

Today, Mark has mastered so many things! He is beginning to understand labels, has started pecs, has 10-15 FUNCTIONAL words, is able to understand how to play with toys and others and so many more things that I credit to your company’s program and the incredible therapists involved in his life. I tell everyone I come in contact (other special need families) with about your company and I know of one family that will be starting with you next week after “firing” her old ABA company after talking with my husband and I.

We can’t wait to see what progress he makes next J He is truly an amazing little boy and your company is an amazing company!! I just wanted to be able to say to you, THANK YOU!!!!!!!!!!!!!!!!!!

Sincerely,
Michelle (I have attached a picture of Mark for you J)

Consumer Guidelines for Selecting Behavior Analysis Programs Serving Children with Autism

Download autism_aig_guidelines.pdf

How to use a variety of point or token systems.

Download how_to_design_a_point_system_revised.doc

Coyne & Associates
Education Corporation

741 Garden View Court, Suite 104
Encinitas, CA 92024
P:(760) 213-1776 F:(760) 634-1530

How To Design A Point System

Paul Coyne Ph.D.

Reinforcement systems can be simple or complex. A simple system is better than a complex one. However, some simple systems are just not effective enough to maintain behavior over time. So, something in between may work best. We will start with a simple type and add elements to make them more effective. Use the simplest system that works.

Simple Designs
1. One simple design: the child follows your instruction. you praise him and provide a pick from the prize basket. The next step is to give him a pick not every time he complies but every 3rd or 4th or 5th time he complies. Vary the schedule for best results.

2. A more formal design is the 5 penny system. On a board draw 5 small circles. Put a piece of Velcro inside each of the circles. Put a corresponding piece of Velcro on each of 5 pennies. When the child complies to an instruction give the child a penny. Have him put the penny in the circle. When all the circles are filled he receives the reinforcer. Sometimes people put a picture of the reinforcer on the 5 penny board so he can see what he is working for. Sometimes that is not a good idea, because somewhere along the line he changes his mind and doesn’t want that reinforcer anymore. So, it may be best to have another board with pictures of several reinforcers. After he earns 5 pennies then he takes a pick from the reinforcer board. A variation of this program is to draw a castle with 5 steps. Have the child place a mark in each step that leads to the castle after some good behavior. When he reaches the castle have him pick from the picture board or the grab bag, or the prize box and so on. Some people use stickers instead of pennies.

3. Another simple design is the numbered dot to dot drawing. Pick a drawing that has about 15 or 10 numbers. You can increase or decrease the amount of numbers depending upon your child. Put a star on every 5th number. Post the drawing on the wall. When the child follows an instruction have him drawn a line from #1 to #2. The next time he follows and instruction have him draw a line from #2 to #3, and so on. When he reaches a star, give him a pick from the picture board. Remember to vary the pictures on the reinforcer picture board so there is always something on the board he will find reinforcing. When he finishes the picture give him a pick plus an extra reinforcer for completing the picture. Notice that in this program the reinforcers build up over time. Drawing the line is reinforcing, plus there is praise. Then he hits a star and gets a reinforcer. As more lines are drawn the picture appears, and at the end he gets an extra reinforcer. Point systems that build up reinforcers over time are effective.

4. Another simple design is the picture puzzle. A favorite photo is cut into X [5?] number of pieces. Each time the does the target behavior (follows your instruction, eats his spinach, plays cooperatively with his sister) he receives a piece of the photo puzzle. The piece is placed on the refrigerator door. When all the pieces are put together and the complete picture is revealed, the child receives his tangible reinforcer. Then a new picture is started. This is one of the most effective token systems. Do not confuse this with the picture schedule described below.

5. The next step in point system design expands this notion of building up reinforcers the longer the child behaves well. Let’s say you have five things you want your child to do each day. Make a list, either a picture schedule or a written list. Let’s take the picture schedule. Each time he does something on the list, he takes the picture off the schedule and gives the picture to you. You then give him a pick from the prize basked or reinforcer menu board. When the 5th picture from the picture schedule is taken off and given to you, he receives a pick from the prize basket and a star for his star chart because he completed all the tasks for the day. When he earns 5 stars, you give him an extra special reinforcer. Adding the star chart will make the whole system more effective. Please note that there is no requirement that the reinforcement ratio be 5. It could be 3 or 8 or 10. Pick the ratio that works with your child. You can start off with a low ratio (3) and work up to a higher ratio (8). Increase the ratio as your child becomes more skilled.

If you wanted to add this component to the picture puzzle system, then give the child a star for his star chart after each photo is completed or simply say that when five completed pictures are on the refrigerator he gets an extra prize. Then take off the pictures and start again.

6. With older children it is best to have a list of behaviors that you want your child to do each day of the week. Determine how much money you want to spend on this program each week. Let’s say it is $7.00. Then you have 700 points to distribute over the week, 100 points each day. If you have 10 tasks for your child to complete then each task could be worth 10 points. Or you could make the less preferred tasks be worth more points than the easy tasks, just so the total still equals 100 maximum points a day. In this system it is always good to have a bonus point category, just in case your child does something good that is not on the list. Then you can give him bonus points. Pick a day of the week when he can trade in his points for money and provide an opportunity for him to make purchases at a favorite store. Once points are earned do not take them away. If your child misbehaves do not give him points, do not take points away. Consequences for misbehavior should be independent of the point system. Once a reinforcer is given do not take it away. [An excellent example of a consequence for misbehavior is the 5 minute work detail, e.g., take out the trash, walk the dog, clean up the dog poop, empty the dishwasher, and so on. When your child misbehaves assign an unpleasant task that takes 5 minutes to complete. ]

7. Sometimes it is effective to give yourself a quota of points you will give your child each day. Remember you are trying to teach your child new skills. You are using these “points” to shape and reinforce behavior. If you wait for him to “earn” the points, you may wait a long time. It is better to say to yourself, I am going to find 10 things each day my child does appropriately and give him “points” for it. It is your job to find examples of good behavior and reinforce them when they occur, especially when your child misbehaves often. Don’t think, “because my child misbehaved X amount today he doesn’t deserve any points.” Don’t wait for him to deserve or earn the reinforcers. Be proactive. Catch him when he is good.

8. Response Cost. Parents often ask whether it is effective to take away points when the child misbehaves. Taking away points contingent upon misbehavior is called “Response Cost”. It is a punishment procedure. There is evidence published in psychology journals that indicate Response Cost procedures can be effective. The risk is if you have a child that frequently misbehaves. If you take away points frequently, the child will rarely come in contact with the reinforcers. It is reinforcement that results in better behavior, not punishment. So, if you have high rates of punishment (you frequently take away points) the aversiveness of the procedure may result in more misbehavior. On the other hand, if your child earns points frequently and only loses a few points here and there, then the combination of earning points and response cost will be more effective than either procedure used alone. One way to mitigate the problems of Response Cost is to have two separate point systems. The regular point system where your child earns points – once earned never taken away. Then have another posted reinforcer for example, TV time. Draw 5 TVs on a piece of paper and tape it to the refrigerator. Each time your child misbehaves mark off (or better yet, have him mark off) one of the TVs. He loses 15 minutes of TV time. If all the TVs are marked off, he loses TV for the day. The next day the paper with the 5 TVs are posted back on the refrigerator – the Response Cost procedure begins again. As you can imagine, there are many variations on this theme.

Purpose

Thank you for visiting the Behavior Analysis & Autism blog. I hope you will find the information helpful. The notion is to provide articles, videos, web links, and so on to people interested in applied behavior analysis and in early intervention programs for children with autism. Some information will be of interest to professionals in the field. Other items will be of interest to parents of children with autism. Your comments are also welcomed.

My name is Paul Coyne PhD. I'm the executive director of Coyne & Associates Education Corporation. Coyne & Associates provides an in-home early intervention program to children with autism who are 12 months to 36 months of age. The teaching techniques we used are based on applied behavior analysis. We also provide services to children with autism who are between the ages of 3 and 12 years old funded through their local school district. Our main office is in Encinitas, CA. We have other offices in San Juan Capistrano and will be opening a new office in Riverside County soon. My email address is: pdcoyne@mac.com Please email me if you have a comment or question. You comment or question may be posted here on the blog.

I will be writing some of the articles or posts on the blog, some will be written by others. If you have a specific question or interest let me know and I will try to address it. I hope to post something to the blog at least once a month so keep checking back for more news and information.