Autism Intervention Every Day!

Embedding Activities in Daily Routines for Young Children and Their Families

by Merle J. Crawford, M.S., OTR/L, BCBA, CIMI
and

Barbara Weber, M.S., CCC-SLP, BCBA

About the Authors

Merle J. Crawford, M.S., OTR/L, BCBA, CIMI, is an occupational therapist who has a private practice in central Pennsylvania. She has a bachelor of science degree in special education and elementary education and a master’s degree in occupational therapy. In addition, Ms. Crawford has graduate certificates in applied behavior analysis and autism. She has extensive training in relationship-based interventions and is a Board Certified Behavior Analyst and a Certified Infant Massage Instructor. Ms. Crawford works primarily with infants and toddlers in early intervention, integrating strategies from her varied training when coaching families and working with young children.

Barbara Weber, M.S., CCC-SLP, BCBA, is a speech-language pathologist who has a private practice in central Pennsylvania. She received her bachelor of science degree and master’s degree in communication disorders. Ms. Weber has a graduate certificate in applied behavior analysis. She holds the Certificate of Clinical Competence from the American Speech-Language-Hearing Association and is a Board Certified Behavior Analyst. She has worked with children and adults with a variety of disabilities for more than 30 years in school, clinic, and home settings. Ms. Weber works with infants and toddlers as her primary clinical focus and concentrates on collaborative processes to help families.

Autism and Early Intervention

Early intervention (EI) providers bring unique expertise and experience to the children and families with whom they work. Knowledge about and experience in working with young children who are on the autism spectrum vary. Some providers feel quite comfortable working with children on the autism spectrum, whereas others do not believe they have the needed skills. Those who believe they do not have the needed skills may pass up referrals for children diagnosed with autism and instead prefer to work with children with challenges for which they have expertise: perhaps children with feeding challenges, medical issues, physical challenges, or sensory impairments.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013), diagnostic criteria for ASD include "persistent deficits in social communication and social interaction" and "restricted, repetitive patterns of behavior, interests, or activities," with symptoms that significantly impair social, occupational, or other important areas of current functioning" (APA, p. 50) that are not explained solely by an intellectual disability or global developmental delay.

Many studies have looked at red flags in order to identify infants and toddlers who have ASD. For example, Wetherby, Watt, Morgan, and Shumway (2007) found that by 18–24 months, there are five social communication core deficits in children with autism: "gaze shift, gaze point/follow, rate of communicating, acts for joint attention, and inventory of gestures" (p. 973).

Autism Speaks, an advocacy organization, presented a list of red flags, including:

• No big smiles or other warm, joyful expressions by six months or thereafter
• No back-and-forth sharing of sounds, smiles, or other facial expressions by nine months
• No babbling by 12 months
• No back-and-forth gestures such as pointing, showing, reaching, or waving by 12 months
• No words by 16 months
• No meaningful two-word phrases (not including imitating or repeating) by 24 months
• Any loss of speech, babbling, or social skills at any age

The Centers for Disease Control and Prevention (CDC; 2014) delineates other red flags, advising that people with autism might exhibit the following behaviors at an early age:

• Not respond to their name by 12 months of age
• Flap their hands, rock their body, or spin in circles
• Have unusual reactions to the way things sound, smell, taste, look, or feel

In working with children with ASD, the authors have found that many everyday occurrences are affected by the child’s skills and preferences (e.g., resisting wearing warmer pajamas when the season changes, being a selective eater, reacting to noise at a birthday party, having difficulties with transitions). Coaching caregivers within these routines provides the learning and support needed to facilitate changes within everyday experiences.

Coaching within daily routines is an efficient process for quickly solving problems and enables caregivers to learn strategies to help their children develop new skills in natural learning contexts. EI providers often need to make families aware that EI services can and should occur within family routines. In the authors’ experiences, some families embrace this easily, whereas with others, it is a process. The families may have experience with other models of services, such as going to an outpatient clinic, or they may have had EI providers who do not have experience using coaching and a family-centered model.

Many parents embrace the coaching model and are very successful at integrating strategies to facilitate their child’s development throughout a variety of daily routines. The authors have found that developing a plan with the caregivers for the next session has helped facilitate coaching within routines. For example, the authors have asked caregivers if they can plan for the child to brush his or her teeth, get dressed, have breakfast, sweep the floors, or go grocery shopping with the caregivers during an upcoming session.