- Email: [email protected]
Technology
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Technology Jonathan Tarbox, Adel C. Najdowski The information technology revolution has changed virtually all aspects of modern society, and autism treatment is no exception. The adoption of technology in autism treatment, however, has lagged behind the adoption of technology in many other disciplines, such as education, medicine, and business. This chapter will provide a discussion of currently available technology solutions and the likely future development of technology in areas such as assessment and curriculum, data collection, training, and telemedicine, among others.
ASSESSMENT AND CURRICULUM Assessment Several advantages of technology-based assessment are worth discussing. First, assessment data are stored electronically, which allows results to be automatically updated and an assessment report to be produced to illustrate a learner’s strengths and needs. If the assessment is linked directly to a curriculum, then the assessment results can help with the treatment planning process in an even more efficient manner. If the assessment is connected to the Internet, then it can allow multiple assessors to log in from their own locations and input data into the same assessment. Likewise, multiple people can log in and view the results of an assessment from various locations. Finally, the capacity of technology to reduce paperwork and eliminate the need to carry around the assessment documents further increases efficiency and improves mobility.
Curriculum Most curricula for autism treatment are still distributed in traditional paper, hard-copy format. These curricula have served practitioners reasonably well, but their format is inherently limiting. First, since the Evidence-Based Treatment for Children with Autism
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Copyright © 2014 Doreen Granpeesheh and Jonathan Tarbox. Published by Elsevier Inc. All rights reserved.
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iscipline of autism treatment is always evolving, paper curricula should d be out of date within a few years after being printed. Of course, new editions can always be printed, but this has occurred, in reality, on such an infrequent basis that most curricula remain outdated. A major advantage of web- or cloud-based curricula is that they can truly be “living documents” that are updated on a continuous basis to reflect the most current evidence base. Second, lessons in paper format are difficult to adapt. As has been made clear in this manual, the analysis portion of applied behavior analysis (ABA) is absolutely critical, and teaching lessons must be customized to meet each individual learner’s needs. Paper lessons need to be retyped and edited (and reprinted) in order to be customized, a waste of time and effort that can be avoided by using editable electronic formats. Given that professional communication often occurs nowadays via electronic formats, information from an electronic curriculum can therefore be copied and pasted into electronic mail to facilitate much more rapid communication among treatment team members. Third, particularly large curriculum books can offer too much information for the practitioner to sift through efficiently at any one time. For example, if a paper curriculum contains hundreds of potential lessons, clinicians must ensure that they consider every possible lesson sufficiently, so they do not miss important lessons that should be taught but get “lost in the shuffle.” Additionally, clinicians may pore over hundreds of pages of curriculum every time they consider what to teach their learner next (i.e., every 2 weeks), but this process robs the clinician of precious time that would be better used treating children. As an alternative, well-designed electronic curricula can solve these problems by organizing and presenting a more streamlined, relevant, and user-friendly amount of information targeted to what the clinician likely needs to see at any given time. For example, if an electronic curriculum is linked to an assessment, then only lessons that the learner has not already mastered are presented to the clinician. In addition, lessons can be sorted by difficulty, prerequisite skills, age of emergence in typical development, and so on, as is done in the Skills® curriculum (see description below). Fourth, comprehensive curricula are massive, and the sheer weight and size that they occupy in paper form make them unwieldy and not amenable to travel or broad dissemination. If ABA is to be disseminated globally, coordination and consultation need to occur across vast distances – perhaps even across continents – in real-time, and the need to have multiple copies of the same paper curriculum in different places around the world for a team to collaborate effectively is unreasonably cumbersome. Fifth, electronic curricula allow for web- or cloud-based progress tracking. Data from a single learner’s treatment program can be tracked and graphed in a single place, making it easily accessible by multiple team
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members from different locations, thereby greatly enhancing interdisciplinary collaboration. Online real-time progress tracking can also greatly enhance a clinical supervisor’s ability to stay abreast of her learners’ progress in home-based programs because it obviates the need to physically bring paper copies of data sheets to the supervisor’s location. Sixth, electronic curricula, if they include progress tracking, hold tremendous potential for research on autism treatment simply because of the data that can be collected. A significant challenge of research on autism treatment is the very large individual differences between children of the same age who receive the same treatment. Very large samples are therefore required to find meaningful relationships between variables of interest and treatment outcome. The need for very large sample sizes, in turn, makes research both expensive and difficult to manage. The result is that very few autism treatment outcome studies are funded, conducted, or published. Large-scale databases that contain outcome data on real-life autism treatment hold the potential to yield answers to questions that have been difficult or impossible to address using traditional research designs. For example, if data on learning rate in ABA programs were contained in a single database, which also contained data on hundreds of other variables that might be relevant to learning outcome, research could address questions such as the optimal intensity, focus, format, and so on, of treatment for children of every conceivable age, IQ level, baseline skill level, and more. Such a database could hold promise for identifying phenotypes, or subtypes, of autism spectrum disorder (ASD) that could be helpful for predicting response to treatment, matching treatment type to child characteristics, and so on. Skills®. CARD has developed an online treatment management platform, Skills® (www.skillsforautism.com), which includes online assessment, curriculum, and progress tracking. The Skills assessment, which has been found to have strong validity (Persicke et al., 2014), covers the eight curriculum domains described in the content section of this manual (Chapters 11–18): social, motor, language, adaptive, play, executive functions, cognition, and academic skills. In addition to the assessment being valid, the language domain of the Skills assessment has been found to be reliable (Dixon, Tarbox, Najdowski, Wilke & Granpeesheh, 2011). When creating a Skills account for a learner and entering her birthdate, the user completes a comprehensive assessment that starts with questions about the learner’s infant skills and continues up to the learner’s chronological age with the goal of determining everything the learner needs to be taught in order to catch up to her typically developing, same-age peers. Each assessment question is directly linked to one or more lesson activities within any of the eight curricula of the Skills program, and each time the assessor indicates that the learner cannot perform a task, the linked lesson activities for that particular item are placed into the learner’s activity
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l ibrary. The user is then able to choose which of the activities in this library to place into the learner’s current treatment program. The curriculum contains almost 4,000 activities, and Skills contains several tools to aid in the process of choosing which activities to prioritize for the learner. First, the lessons are all categorized by difficulty level, from 1 (easiest) to 12 (most advanced). All other things being equal, clinicians should start with lowest level lessons first. Second, all activities have a developmental age assigned to them. Generally speaking, skills that emerge earlier in typical development should be introduced before older skills, as long as they are currently relevant to the learner’s life. Third, prerequisite skills are identified for all activities, so a particular activity should not be introduced before its prerequisite skills are mastered. Fourth, all the activities are categorized as one of three types: 1) building block, 2) fundamental skill, and 3) expansion skill. A building block is not a legitimate skill in and of itself; rather, it is a stepping stone toward a fundamental skill that is the real meaningful skill used in daily life. An expansion skill goes above and beyond a fundamental skill and is considered more of an enrichment activity that would be used with a child for whom one expects best outcomes. We advise clinicians to think about the profiles of their learners and choose their activities wisely. For example, when working with a child who is a fast learner, it might be unnecessary to spend time teaching building blocks. Perhaps that type of learner can go straight into learning the fundamentals and then onto expansions without every really needing building blocks. It’s fine to skip building blocks because they are not the truly meaningful skill; however, it should be noted that they are important intermediate steps that can be very helpful for learners who need to learn in smaller steps. With this type of learner, the clinician might choose to start with building blocks and end at fundamental skills, ignoring expansion skills. After choosing the activities to place in the treatment program, the clinician then teaches those skills and inputs data along the way. All authorized caregivers, health care providers, teachers, and other professionals can then track the learner’s progress in Skills online. All of this information is displayed in the learner’s progress charts and incorporated into her progress reports. Data on learning are automatically graphed over time. The clinician also has the ability to input data on challenging behavior, and these data are then automatically superimposed on data on learning rate in order for the clinician to observe the relationship, if any, between challenging behavior and learning rate. In addition, the clinician can input any other relevant life events that may impact challenging behavior or learning, such as medication changes, changes in school placement, illness, changes in treatment intensity, and so on. All of these variables can be viewed together or separately, so the clinician can analyze the extent to which they influence one another.
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TEACHING TECHNOLOGY Games and Applications Hundreds, if not thousands, of teaching games and apps are currently available for children with ASD. In theory, such applications can be beneficial because they provide teaching opportunities to learners when clinicians might otherwise be unable to provide their undivided attention to the learner or when the learner is not in a direct instructional environment. In some cases, the games/apps can even be used as reinforcers for the learner during downtime. In these cases, the learner is able to continue learning even during breaks from therapist-delivered therapy. Despite the many potential benefits of computer applications for teaching children with ASD, there are many limitations inherent in what is currently available. First, at the time of the publication of this manual, with the exception of one or two studies, none of the hundreds of currently available teaching apps have any research supporting their effectiveness. Therefore, it is presently unknown whether 99% of the currently available apps actually work. Second, the vast majority of educational games and apps are designed by people who are not experts in treating children with ASD. Therefore, even a casual review of most apps reveals that they are not based on any principles or procedures known to be effective in teaching children with ASD. Most apps don’t include even the most basic elements of effective prompting, reinforcement, and prompt-fading procedures that actually result in skill acquisition in the autism population. A third significant limitation of teaching apps that are currently available is that the present state of technology does not yet allow most skills to be taught. Virtually all teaching apps currently require a response from the student in the form of touching a screen or clicking a mouse, so skills that require any other form of response are still a long way off from being teachable on an app. For example, expressive vocal language is difficult to teach with a computer because speech recognition technology is still primitive, although it is improving rapidly. Although it has been used successfully to teach second languages to typically developing individuals, at the time this manual goes to press, it has not yet been successfully applied to teaching children with ASD. Motion-sensing technology for teaching motor skills to children with ASD has also not yet been invented, although that is in development at several centers and will likely be available soon. We expect that the next 5 years will bring significant advancements in the development of apps for teaching children with ASD, but we hope those advances will be accompanied by sound scientific research and that app development will be based on published research on teaching procedures that work for children with ASD. The future of autism intervention
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will almost certainly include an important place for technology that directly teaches learners with ASD. The first forays have already been made into this area with very mixed results, but some progress has already been made. At the moment, these types of programs should, at most, be used to supplement human-delivered ABA therapy. ABA consists of engineering the learner’s teaching environment to cause learning. If a computer is made a significant part of the learner’s environment (and for many learners it already is), then it follows that computers should be able to teach learners with ASD and potentially replace a significant portion of human-delivered ABA. Computerized ABA-based instruction offers many possible advantages, including increased procedural integrity, automated data collection and progress tracking, increased access to treatment, and the potential to decrease the costs of ABA treatment. To be clear, the day that research demonstrates that any portion of human-delivered ABA treatment can be replaced by computer-delivered teaching is very far off, but it seems likely that this will be the case in the future. Robotics. At some point, it seems likely that robots will be developed that can perform at least some portion of teaching for people with and without disabilities, and there is no clear reason that children with ASD could not also benefit. Using robots to deliver instruction would essentially be the same as a child with ASD learning from an app on a tablet or computer, except that the computer can walk, talk, make facial expressions, and potentially learn from its interactions with the child. Of course, if the robot is not capable of natural social interactions, it will not be likely to be useful for teaching social skills. However, especially for children with ASD who are particularly interested in technology, robots may turn out to be an effective option for teaching nonsocial content.
COMMUNICATION APPLICATIONS Just as people once searched for the perfect communication device, they are now on the hunt for the perfect communication application, or app. Many different communication apps are available today. Regardless of which one you choose to use with your learners, you will need to customize the vocabulary and the layout for the learner and teach him how to use it. There aren’t really any communication apps that the learner can simply pick up and start using without some direct training. In fact, some learners will even need to be trained to use their index fingers properly to activate buttons correctly. Button sensitivity can be adjusted on many apps, but in an extreme case you can purchase grids that lay over the screen to physically prevent the learner from moving his finger sideways over too many buttons. Many communication apps provide flexibility for customization by allowing you to upload your own photos, record sounds or voiceover, and
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so on. The advantage of using a communication app is that it provides non- vocal or limited vocal learners with a method of communication. Although the research on their effects on speech is still emerging, our clinicians anecdotally report that, in many cases, learners who use communication apps increase their vocalizations. Another advantage of communication apps is that they offer a portable solution without the requirement to print out, laminate, adhere, and keep track of (try not to misplace or lose) picture cards.
CHALLENGING BEHAVIOR MANAGEMENT The development of technology tools for managing challenging behavior is emerging. A couple of online tools are available for conducting functional behavioral assessments (FBA) and developing behavior intervention plans (BIPs), one of which is the Skills® BIP Builder (www.skillsbipbuilder.com). These types of tools use an indirect assessment to ask the user questions related to the function of the challenging behavior. Based on the answers to the questions and accompanying summary of the results, the user is able to identify the most plausible function. At that point, the user begins the process of building a BIP based on the hypothesized function of the challenging behavior using antecedent, replacement behavior, and consequence treatment components. An advantage of using electronic tools for building BIPs is that, if programmed correctly, they automatically present only function and evidence-based treatment components. Moreover, by using a decision matrix based on the answers to questions about the challenging behavior, a BIP builder can be programmed to present least intrusive interventions first. This type of technology has been shown to increase the use of function-based interventions (Tarbox et al., 2013). Such tools also ensure that the clinician doesn’t forget to include antecedent modifications, a replacement behavior, and consequence manipulations, while making sure the clinician also remembers all of the function and evidence-based options from which to choose. Not only does this presumably make the clinician more efficient with her time creating the BIP, but it is also a great way to give educational staff who are less familiar with writing BIPs (but whose job descriptions require it) access to tools based on best practices for writing BIPs.
OTHER CLINICAL TOOLS Technology is useful in various capacities to assist the clinical supervisor in designing lesson activities to be carried out with learners. For example, clinicians can find 2D pictures online or via applications to use
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as stimuli during assessment and/or in lesson activities. Technology also offers other tools to be used during therapy, such as electronic token economies, activity schedules, and visual timers for the learner to view the passage of time when learning to “wait” or when implementing a differential reinforcement of other behavior (DRO) procedure. Pagers and special watches have been used to prompt learners (either by vibrating or beeping) to engage in appropriate behaviors, and alarms exist for teaching learners to stop bed wetting. These are just a few of the many examples of handy technology innovations meant for assisting in the delivery of autism treatment.
DATA COLLECTION In Chapter 20, we discussed the importance of careful data collection during the course of comprehensive behavioral intervention for learners with ASD. The vast majority of data collection in behavioral intervention programs is still done with pen and paper. Paper datasheets are then stored for extended periods of time, and data from them may or may not be transferred to relatively low-tech electronic storage methods, such as Microsoft Excel files, or relatively higher-tech storage, such as networked databases. This method of data collection has served the early intensive behavioral intervention (EIBI) field well for the past several decades; however, it is outdated and unwieldy. Sometime in the near future, it seems almost certain that electronic data collection, analysis, and storage will become the norm. Several potential benefits of electronic data collection are apparent. For example, intelligent data collection apps will allow for automated transfer of data to centralized databases, automated graphing of data for ongoing clinical analysis, and automated summary of data for reporting purposes. All of these features, if executed well, could decrease the number of person-hours required for case management and reporting, as well as make wireless, real-time clinical case management possible from anywhere in the world with an Internet connection. Just as exciting, electronic storage of data holds the promise of allowing analyses to be conducted that would have required onerous amounts of time to be allocated to data entry and analysis. For example, if 1,000 learners were receiving behavioral intervention and their data were automatically uploaded to a database that was equipped for sophisticated data mining and analytics, a vast array of clinically important questions could be addressed quantitatively. For example, What is the mean and range number of trials to acquisition for a particular skill? How do age, number of treatment hours per week, gender, treatment setting, and any other number of variables influence skill acquisition? What effects, if any, do the credentials, years of experience, number
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of members on a team, and a whole host of other therapist variables have on learning rate for the child? What effect, if any, do weather, region, season, or number of hours of daylight have on learning outcome? In short, if everyday autism treatment data could be analyzed from a truly “big data” standpoint, hundreds of questions could be addressed that would simply never be addressed using traditional research methodology for financial, logistical, and ethical reasons. At the time this manual goes to press, real-time electronic data collection during behavioral intervention is still in its infancy. While apps are being marketed for this purpose, the vast majority of them fall short in a number of ways, primarily because electronic data collection has a number of inherent potential limitations. First, therapists are still far more fluent with pencil and paper than they are with any electronic device, such that it is still almost inevitable that therapists will require more time to tap a phone or tablet than to make a brief mark on paper. As wireless devices integrate themselves into every aspect of our lives, this may change. Perhaps pens and pencils will be a thing of the past in coming decades, but a current critical concern when choosing whether to use electronic data collection is how much time it requires of the therapists. A recent study evaluating electronic data collection on handheld computers found that electronic data collection required significantly more time than pen and paper data collection and likely slowed down the pace of therapy considerably (Tarbox, Wilke, FindelPyles, Bergstrom & Granpeesheh, 2010). A second potential limitation is that data collection can be limited by the interface that the application provides. In other words, one can only collect the data that the computer program allows one to collect. With pen and paper data, therapists are free to rapidly jot down notes of any sort about any topic, should the need arise. Presumably, data collection applications will be adapted to allow rapid descriptive note taking at some point, but this is a significant concern at this time. CARD has recently developed a tablet-based software application for data collection and management called Skills LogBook™, which is designed to address the limitations described above. Skills LogBook™ runs on an iPad that each therapist uses while conducting therapy. The software allows therapists to collect acquisition and challenging behavior data and replaces a therapist’s paper/pencil logbook or data sheets. Skills LogBook™ is linked directly to each individual learner’s Skills account, so when therapists need to collect discrete trial training (DTT) data, they are able to select from all of the lessons that are currently in acquisition or mastered in the learner’s program, as well as the particular exemplars to be taught during that session. The software automatically selects whether the lesson should be taught in mass trial, random rotation, or expanded trials (Chapter 4) based on the data that were collected the last time that lesson
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was taught. The supervisor has the ability to adjust mastery criteria and other details of how the software determines lesson phases. When the therapist is ready to begin conducting the lesson with the learner, the screen of the iPad resembles a standard discrete trial datasheet. At the top of the sheet is a notes section that is automatically updated with the latest notes that the supervisor entered into Skills for that particular lesson. In addition, Skills LogBook™ displays any notes regarding challenging behavior management that the supervisor has entered into the system. Each iPad is wirelessly connected to the central Skills server, so every time a lesson is conducted, the data are automatically and wirelessly updated in Skills. This gives the supervisor the ability to add notes for the therapist in real time from anywhere in the world with an Internet connection. At the time this manual goes to press, Skills LogBook™ is being used for internal purposes only, but it will be made commercially available in the near future.
CARE COORDINATION AND CASE MANAGEMENT A new development in autism treatment is the use of technology as a means for insurance agencies to carry out care coordination and case management. Using various treatment management software programs, of which Skills is one, insurance carriers are now able to allow their case managers to log into a learner’s account and view real-time progress, obtain reports, and, ultimately, make decisions about the learner’s future funding. The availability of this type of technology has been useful for increasing the ability of autism treatment agencies to communicate directly with insurance carriers and for care coordination to be carried out seamlessly. In the foreseeable future, once tens of thousands of learners’ assessments and curriculum progress are saved in databases and tracked using such software programs, the face of funding for autism treatment as we know it will likely change. That is, algorithms should emerge that are capable of using individual profiles to predict a learner’s potential progress within given treatment parameters. If this happens, the number of hours requested for funding should be generated directly from a computer program, eliminating the often arbitrary decision-making process of the funding agencies. If the analyses are based on valid data, then this would represent a shift toward data-based decision making on the part of funding agencies – something that is all but lacking today – while preserving the processes that enable families to challenge insurance carriers when necessary. Such computer programs should also allow funding agencies – and potentially consumers – to view quality rankings of autism treatment agencies in terms of their level of progress with the learners they serve in relation to other agencies and even among various clinical supervisors within the same organization. This should help improve the quality of
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ABA service delivery as a whole by increasing accountability within the field and eventually weeding out the less effective clinicians, as their ability to obtain funding for their services will eventually be eliminated until they receive more training and demonstrate improvement.
TRAINING The need for global dissemination of expertise in ABA is great, and one of the largest bottlenecks is the availability of expert trainers. Web-based training is a promising method for addressing this need. Research comparing web-based training to in-person training for establishing clinical competence in ABA practitioners is still very much in its infancy, but the initial results are encouraging, both for training staff (Granpeesheh et al., 2010) and parents of children with autism (Jang et al., 2012). It seems unlikely that web-based staff training, no matter how sophisticated, will ever completely circumvent the need for human interaction in training, nor would we want it to do so. It seems likely, however, that web-based staff training will prove to increase the cost-effectiveness of disseminating staff training across longer distances and larger regions by reducing the number of hours of in-person training required and/or decreasing the number of in-person visits required by an expert trainer. A good model for incorporating web-based training is likely to be used as a replacement for some portion of classroom didactic training. In other words, it seems likely that some or all of the time that trainees would normally spend listening to a lecture in a classroom could be replaced by self-paced web-based training as long as it is followed by in-person performance feedback and on-the-job training. Technology-based trainings currently come in all different shapes, sizes, and modes of delivering content, including use of computer-animated videos; recorded human-delivered lecture with PowerPoint; narrated videos of procedures being carried out with learners; and interactive technology wherein trainees receive instruction and feedback while attempting to carry out procedures with a computer-animated learner.
Institute for Behavioral Training (IBT) CARD’s training materials for staff, educators, and parents are now available online in an eLearning format through the Institute for Behavioral Training (IBT; www.ibehavioraltraining.com). The format of the training is PowerPoint combined with videotaped lecture and examples of therapists demonstrating procedures with learners. These eLearning training modules are used all over the world by anyone interested in learning more about the delivery of behavioral intervention to learners with ASD.
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TELEMEDICINE The field of telemedicine is experiencing a rapid evolution in the utilization of technology to facilitate the practice of medicine across great distances. As a field, telemedicine essentially involves interacting in real time with a patient, provider, and/or caregiver via video or telephone conferencing or reviewing stored videos and patient data and includes diagnosing a problem and prescribing an intervention, as well as providing consultation to others who provide treatment. Although scientific evidence for telemedicine is still emerging, the world’s leading medical institutions now have satellite hospitals, and it appears that the use of telemedicine will only continue to grow. Telemedicine is useful in the delivery of behavioral intervention to geographically remote areas in which families would otherwise go without services. Some research has shown that it can be used to train individuals to carry out specific procedures for particular behaviors. The CARD Model uses telemedicine combined with in-person training and supervision in its Remote Clinical Services model. The iPads used for Skills LogBook™ (described above) can also be used to run live videoconferencing software, so supervisors in one part of the world can watch the therapist working with the learner and give live feedback. See Chapter 28 for more details on this model.
ABA BUSINESS MANAGEMENT SOLUTIONS In the field of ABA, most service provision agencies have been founded by clinicians providing services to individuals with ASD. However, as with any other business, many processes are required in order to effectively schedule sessions, track services rendered, submit billing, generate payroll, manage revenue, track training progress, and manage records. Technology now offers online management solutions for ABA agencies to use in conducting all of the above. While such solutions are currently in their infancy, this is an area that will likely progress quickly, resulting in streamlining the way in which ABA service agencies manage their business.
COMMUNITY OUTREACH The basic concept behind dissemination efforts – whether in the form of web-based training, such as that contained in IBT, or writing the book you are currently reading – is to provide information that empowers families living with ASD around the world to live better lives. Recent developments in web-based social networks and social media have shown the
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amazing power that technology has to bring people together and share ideas, if used effectively and with noble intent. Web-based networks and video-sharing platforms have transformed commercial, social, and political life in dramatic ways to the point where political and social revolutions can be sparked by the appearance of video content that deals with the right issues at the right time. Toward this end, CARD has actively participated in a number of technology-based community outreach efforts. For example, Dr. Doreen Granpeesheh hosted a monthly web-based radio show on Autism One Radio for several years called The ABA Piece of the Puzzle. Each monthly show provided practical information for parents and practitioners on one specific topic within ABA. More recently, CARD founded Autism Live, a web show (www.autism-live.com) that is broadcast live over the web, 2 hours per day, 3 days per week. The program is hosted by Shannon Penrod (autism mom, expert, and activist) and consists of live conversations with experts from a variety of fields relevant to ASD. In addition, Autism Live contains specialty features on a wide variety of topics, ranging from cooking, to vacations with children on the spectrum, to how to have more fun in your daily life. The purpose of Autism Live is to provide genuine hope by giving information that empowers families living with ASD to live fuller lives.
SUMMARY Technology is a powerful driving force in the future of autism treatment. While technology is currently being used in many ways to assist in the provision of services and training, the potential for future developments and their implications for the evolution of autism treatment are vast. The CARD Model values technology and is committed to leading the development of technology solutions that help achieve the mission of providing global access to top-quality treatment to as many families affected by autism as possible.
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Technology Jonathan Tarbox, Adel C. Najdowski The information technology revolution has changed virtually all aspects of modern society, and autism treatment is no exception. The adoption of technology in autism treatment, however, has lagged behind the adoption of technology in many other disciplines, such as education, medicine, and business. This chapter will provide a discussion of currently available technology solutions and the likely future development of technology in areas such as assessment and curriculum, data collection, training, and telemedicine, among others.
ASSESSMENT AND CURRICULUM Assessment Several advantages of technology-based assessment are worth discussing. First, assessment data are stored electronically, which allows results to be automatically updated and an assessment report to be produced to illustrate a learner’s strengths and needs. If the assessment is linked directly to a curriculum, then the assessment results can help with the treatment planning process in an even more efficient manner. If the assessment is connected to the Internet, then it can allow multiple assessors to log in from their own locations and input data into the same assessment. Likewise, multiple people can log in and view the results of an assessment from various locations. Finally, the capacity of technology to reduce paperwork and eliminate the need to carry around the assessment documents further increases efficiency and improves mobility.
Curriculum Most curricula for autism treatment are still distributed in traditional paper, hard-copy format. These curricula have served practitioners reasonably well, but their format is inherently limiting. First, since the Evidence-Based Treatment for Children with Autism
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Copyright © 2014 Doreen Granpeesheh and Jonathan Tarbox. Published by Elsevier Inc. All rights reserved.
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iscipline of autism treatment is always evolving, paper curricula should d be out of date within a few years after being printed. Of course, new editions can always be printed, but this has occurred, in reality, on such an infrequent basis that most curricula remain outdated. A major advantage of web- or cloud-based curricula is that they can truly be “living documents” that are updated on a continuous basis to reflect the most current evidence base. Second, lessons in paper format are difficult to adapt. As has been made clear in this manual, the analysis portion of applied behavior analysis (ABA) is absolutely critical, and teaching lessons must be customized to meet each individual learner’s needs. Paper lessons need to be retyped and edited (and reprinted) in order to be customized, a waste of time and effort that can be avoided by using editable electronic formats. Given that professional communication often occurs nowadays via electronic formats, information from an electronic curriculum can therefore be copied and pasted into electronic mail to facilitate much more rapid communication among treatment team members. Third, particularly large curriculum books can offer too much information for the practitioner to sift through efficiently at any one time. For example, if a paper curriculum contains hundreds of potential lessons, clinicians must ensure that they consider every possible lesson sufficiently, so they do not miss important lessons that should be taught but get “lost in the shuffle.” Additionally, clinicians may pore over hundreds of pages of curriculum every time they consider what to teach their learner next (i.e., every 2 weeks), but this process robs the clinician of precious time that would be better used treating children. As an alternative, well-designed electronic curricula can solve these problems by organizing and presenting a more streamlined, relevant, and user-friendly amount of information targeted to what the clinician likely needs to see at any given time. For example, if an electronic curriculum is linked to an assessment, then only lessons that the learner has not already mastered are presented to the clinician. In addition, lessons can be sorted by difficulty, prerequisite skills, age of emergence in typical development, and so on, as is done in the Skills® curriculum (see description below). Fourth, comprehensive curricula are massive, and the sheer weight and size that they occupy in paper form make them unwieldy and not amenable to travel or broad dissemination. If ABA is to be disseminated globally, coordination and consultation need to occur across vast distances – perhaps even across continents – in real-time, and the need to have multiple copies of the same paper curriculum in different places around the world for a team to collaborate effectively is unreasonably cumbersome. Fifth, electronic curricula allow for web- or cloud-based progress tracking. Data from a single learner’s treatment program can be tracked and graphed in a single place, making it easily accessible by multiple team
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members from different locations, thereby greatly enhancing interdisciplinary collaboration. Online real-time progress tracking can also greatly enhance a clinical supervisor’s ability to stay abreast of her learners’ progress in home-based programs because it obviates the need to physically bring paper copies of data sheets to the supervisor’s location. Sixth, electronic curricula, if they include progress tracking, hold tremendous potential for research on autism treatment simply because of the data that can be collected. A significant challenge of research on autism treatment is the very large individual differences between children of the same age who receive the same treatment. Very large samples are therefore required to find meaningful relationships between variables of interest and treatment outcome. The need for very large sample sizes, in turn, makes research both expensive and difficult to manage. The result is that very few autism treatment outcome studies are funded, conducted, or published. Large-scale databases that contain outcome data on real-life autism treatment hold the potential to yield answers to questions that have been difficult or impossible to address using traditional research designs. For example, if data on learning rate in ABA programs were contained in a single database, which also contained data on hundreds of other variables that might be relevant to learning outcome, research could address questions such as the optimal intensity, focus, format, and so on, of treatment for children of every conceivable age, IQ level, baseline skill level, and more. Such a database could hold promise for identifying phenotypes, or subtypes, of autism spectrum disorder (ASD) that could be helpful for predicting response to treatment, matching treatment type to child characteristics, and so on. Skills®. CARD has developed an online treatment management platform, Skills® (www.skillsforautism.com), which includes online assessment, curriculum, and progress tracking. The Skills assessment, which has been found to have strong validity (Persicke et al., 2014), covers the eight curriculum domains described in the content section of this manual (Chapters 11–18): social, motor, language, adaptive, play, executive functions, cognition, and academic skills. In addition to the assessment being valid, the language domain of the Skills assessment has been found to be reliable (Dixon, Tarbox, Najdowski, Wilke & Granpeesheh, 2011). When creating a Skills account for a learner and entering her birthdate, the user completes a comprehensive assessment that starts with questions about the learner’s infant skills and continues up to the learner’s chronological age with the goal of determining everything the learner needs to be taught in order to catch up to her typically developing, same-age peers. Each assessment question is directly linked to one or more lesson activities within any of the eight curricula of the Skills program, and each time the assessor indicates that the learner cannot perform a task, the linked lesson activities for that particular item are placed into the learner’s activity
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l ibrary. The user is then able to choose which of the activities in this library to place into the learner’s current treatment program. The curriculum contains almost 4,000 activities, and Skills contains several tools to aid in the process of choosing which activities to prioritize for the learner. First, the lessons are all categorized by difficulty level, from 1 (easiest) to 12 (most advanced). All other things being equal, clinicians should start with lowest level lessons first. Second, all activities have a developmental age assigned to them. Generally speaking, skills that emerge earlier in typical development should be introduced before older skills, as long as they are currently relevant to the learner’s life. Third, prerequisite skills are identified for all activities, so a particular activity should not be introduced before its prerequisite skills are mastered. Fourth, all the activities are categorized as one of three types: 1) building block, 2) fundamental skill, and 3) expansion skill. A building block is not a legitimate skill in and of itself; rather, it is a stepping stone toward a fundamental skill that is the real meaningful skill used in daily life. An expansion skill goes above and beyond a fundamental skill and is considered more of an enrichment activity that would be used with a child for whom one expects best outcomes. We advise clinicians to think about the profiles of their learners and choose their activities wisely. For example, when working with a child who is a fast learner, it might be unnecessary to spend time teaching building blocks. Perhaps that type of learner can go straight into learning the fundamentals and then onto expansions without every really needing building blocks. It’s fine to skip building blocks because they are not the truly meaningful skill; however, it should be noted that they are important intermediate steps that can be very helpful for learners who need to learn in smaller steps. With this type of learner, the clinician might choose to start with building blocks and end at fundamental skills, ignoring expansion skills. After choosing the activities to place in the treatment program, the clinician then teaches those skills and inputs data along the way. All authorized caregivers, health care providers, teachers, and other professionals can then track the learner’s progress in Skills online. All of this information is displayed in the learner’s progress charts and incorporated into her progress reports. Data on learning are automatically graphed over time. The clinician also has the ability to input data on challenging behavior, and these data are then automatically superimposed on data on learning rate in order for the clinician to observe the relationship, if any, between challenging behavior and learning rate. In addition, the clinician can input any other relevant life events that may impact challenging behavior or learning, such as medication changes, changes in school placement, illness, changes in treatment intensity, and so on. All of these variables can be viewed together or separately, so the clinician can analyze the extent to which they influence one another.
Teaching Technology
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TEACHING TECHNOLOGY Games and Applications Hundreds, if not thousands, of teaching games and apps are currently available for children with ASD. In theory, such applications can be beneficial because they provide teaching opportunities to learners when clinicians might otherwise be unable to provide their undivided attention to the learner or when the learner is not in a direct instructional environment. In some cases, the games/apps can even be used as reinforcers for the learner during downtime. In these cases, the learner is able to continue learning even during breaks from therapist-delivered therapy. Despite the many potential benefits of computer applications for teaching children with ASD, there are many limitations inherent in what is currently available. First, at the time of the publication of this manual, with the exception of one or two studies, none of the hundreds of currently available teaching apps have any research supporting their effectiveness. Therefore, it is presently unknown whether 99% of the currently available apps actually work. Second, the vast majority of educational games and apps are designed by people who are not experts in treating children with ASD. Therefore, even a casual review of most apps reveals that they are not based on any principles or procedures known to be effective in teaching children with ASD. Most apps don’t include even the most basic elements of effective prompting, reinforcement, and prompt-fading procedures that actually result in skill acquisition in the autism population. A third significant limitation of teaching apps that are currently available is that the present state of technology does not yet allow most skills to be taught. Virtually all teaching apps currently require a response from the student in the form of touching a screen or clicking a mouse, so skills that require any other form of response are still a long way off from being teachable on an app. For example, expressive vocal language is difficult to teach with a computer because speech recognition technology is still primitive, although it is improving rapidly. Although it has been used successfully to teach second languages to typically developing individuals, at the time this manual goes to press, it has not yet been successfully applied to teaching children with ASD. Motion-sensing technology for teaching motor skills to children with ASD has also not yet been invented, although that is in development at several centers and will likely be available soon. We expect that the next 5 years will bring significant advancements in the development of apps for teaching children with ASD, but we hope those advances will be accompanied by sound scientific research and that app development will be based on published research on teaching procedures that work for children with ASD. The future of autism intervention
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will almost certainly include an important place for technology that directly teaches learners with ASD. The first forays have already been made into this area with very mixed results, but some progress has already been made. At the moment, these types of programs should, at most, be used to supplement human-delivered ABA therapy. ABA consists of engineering the learner’s teaching environment to cause learning. If a computer is made a significant part of the learner’s environment (and for many learners it already is), then it follows that computers should be able to teach learners with ASD and potentially replace a significant portion of human-delivered ABA. Computerized ABA-based instruction offers many possible advantages, including increased procedural integrity, automated data collection and progress tracking, increased access to treatment, and the potential to decrease the costs of ABA treatment. To be clear, the day that research demonstrates that any portion of human-delivered ABA treatment can be replaced by computer-delivered teaching is very far off, but it seems likely that this will be the case in the future. Robotics. At some point, it seems likely that robots will be developed that can perform at least some portion of teaching for people with and without disabilities, and there is no clear reason that children with ASD could not also benefit. Using robots to deliver instruction would essentially be the same as a child with ASD learning from an app on a tablet or computer, except that the computer can walk, talk, make facial expressions, and potentially learn from its interactions with the child. Of course, if the robot is not capable of natural social interactions, it will not be likely to be useful for teaching social skills. However, especially for children with ASD who are particularly interested in technology, robots may turn out to be an effective option for teaching nonsocial content.
COMMUNICATION APPLICATIONS Just as people once searched for the perfect communication device, they are now on the hunt for the perfect communication application, or app. Many different communication apps are available today. Regardless of which one you choose to use with your learners, you will need to customize the vocabulary and the layout for the learner and teach him how to use it. There aren’t really any communication apps that the learner can simply pick up and start using without some direct training. In fact, some learners will even need to be trained to use their index fingers properly to activate buttons correctly. Button sensitivity can be adjusted on many apps, but in an extreme case you can purchase grids that lay over the screen to physically prevent the learner from moving his finger sideways over too many buttons. Many communication apps provide flexibility for customization by allowing you to upload your own photos, record sounds or voiceover, and
Other Clinical Tools
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so on. The advantage of using a communication app is that it provides non- vocal or limited vocal learners with a method of communication. Although the research on their effects on speech is still emerging, our clinicians anecdotally report that, in many cases, learners who use communication apps increase their vocalizations. Another advantage of communication apps is that they offer a portable solution without the requirement to print out, laminate, adhere, and keep track of (try not to misplace or lose) picture cards.
CHALLENGING BEHAVIOR MANAGEMENT The development of technology tools for managing challenging behavior is emerging. A couple of online tools are available for conducting functional behavioral assessments (FBA) and developing behavior intervention plans (BIPs), one of which is the Skills® BIP Builder (www.skillsbipbuilder.com). These types of tools use an indirect assessment to ask the user questions related to the function of the challenging behavior. Based on the answers to the questions and accompanying summary of the results, the user is able to identify the most plausible function. At that point, the user begins the process of building a BIP based on the hypothesized function of the challenging behavior using antecedent, replacement behavior, and consequence treatment components. An advantage of using electronic tools for building BIPs is that, if programmed correctly, they automatically present only function and evidence-based treatment components. Moreover, by using a decision matrix based on the answers to questions about the challenging behavior, a BIP builder can be programmed to present least intrusive interventions first. This type of technology has been shown to increase the use of function-based interventions (Tarbox et al., 2013). Such tools also ensure that the clinician doesn’t forget to include antecedent modifications, a replacement behavior, and consequence manipulations, while making sure the clinician also remembers all of the function and evidence-based options from which to choose. Not only does this presumably make the clinician more efficient with her time creating the BIP, but it is also a great way to give educational staff who are less familiar with writing BIPs (but whose job descriptions require it) access to tools based on best practices for writing BIPs.
OTHER CLINICAL TOOLS Technology is useful in various capacities to assist the clinical supervisor in designing lesson activities to be carried out with learners. For example, clinicians can find 2D pictures online or via applications to use
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as stimuli during assessment and/or in lesson activities. Technology also offers other tools to be used during therapy, such as electronic token economies, activity schedules, and visual timers for the learner to view the passage of time when learning to “wait” or when implementing a differential reinforcement of other behavior (DRO) procedure. Pagers and special watches have been used to prompt learners (either by vibrating or beeping) to engage in appropriate behaviors, and alarms exist for teaching learners to stop bed wetting. These are just a few of the many examples of handy technology innovations meant for assisting in the delivery of autism treatment.
DATA COLLECTION In Chapter 20, we discussed the importance of careful data collection during the course of comprehensive behavioral intervention for learners with ASD. The vast majority of data collection in behavioral intervention programs is still done with pen and paper. Paper datasheets are then stored for extended periods of time, and data from them may or may not be transferred to relatively low-tech electronic storage methods, such as Microsoft Excel files, or relatively higher-tech storage, such as networked databases. This method of data collection has served the early intensive behavioral intervention (EIBI) field well for the past several decades; however, it is outdated and unwieldy. Sometime in the near future, it seems almost certain that electronic data collection, analysis, and storage will become the norm. Several potential benefits of electronic data collection are apparent. For example, intelligent data collection apps will allow for automated transfer of data to centralized databases, automated graphing of data for ongoing clinical analysis, and automated summary of data for reporting purposes. All of these features, if executed well, could decrease the number of person-hours required for case management and reporting, as well as make wireless, real-time clinical case management possible from anywhere in the world with an Internet connection. Just as exciting, electronic storage of data holds the promise of allowing analyses to be conducted that would have required onerous amounts of time to be allocated to data entry and analysis. For example, if 1,000 learners were receiving behavioral intervention and their data were automatically uploaded to a database that was equipped for sophisticated data mining and analytics, a vast array of clinically important questions could be addressed quantitatively. For example, What is the mean and range number of trials to acquisition for a particular skill? How do age, number of treatment hours per week, gender, treatment setting, and any other number of variables influence skill acquisition? What effects, if any, do the credentials, years of experience, number
Data Collection
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of members on a team, and a whole host of other therapist variables have on learning rate for the child? What effect, if any, do weather, region, season, or number of hours of daylight have on learning outcome? In short, if everyday autism treatment data could be analyzed from a truly “big data” standpoint, hundreds of questions could be addressed that would simply never be addressed using traditional research methodology for financial, logistical, and ethical reasons. At the time this manual goes to press, real-time electronic data collection during behavioral intervention is still in its infancy. While apps are being marketed for this purpose, the vast majority of them fall short in a number of ways, primarily because electronic data collection has a number of inherent potential limitations. First, therapists are still far more fluent with pencil and paper than they are with any electronic device, such that it is still almost inevitable that therapists will require more time to tap a phone or tablet than to make a brief mark on paper. As wireless devices integrate themselves into every aspect of our lives, this may change. Perhaps pens and pencils will be a thing of the past in coming decades, but a current critical concern when choosing whether to use electronic data collection is how much time it requires of the therapists. A recent study evaluating electronic data collection on handheld computers found that electronic data collection required significantly more time than pen and paper data collection and likely slowed down the pace of therapy considerably (Tarbox, Wilke, FindelPyles, Bergstrom & Granpeesheh, 2010). A second potential limitation is that data collection can be limited by the interface that the application provides. In other words, one can only collect the data that the computer program allows one to collect. With pen and paper data, therapists are free to rapidly jot down notes of any sort about any topic, should the need arise. Presumably, data collection applications will be adapted to allow rapid descriptive note taking at some point, but this is a significant concern at this time. CARD has recently developed a tablet-based software application for data collection and management called Skills LogBook™, which is designed to address the limitations described above. Skills LogBook™ runs on an iPad that each therapist uses while conducting therapy. The software allows therapists to collect acquisition and challenging behavior data and replaces a therapist’s paper/pencil logbook or data sheets. Skills LogBook™ is linked directly to each individual learner’s Skills account, so when therapists need to collect discrete trial training (DTT) data, they are able to select from all of the lessons that are currently in acquisition or mastered in the learner’s program, as well as the particular exemplars to be taught during that session. The software automatically selects whether the lesson should be taught in mass trial, random rotation, or expanded trials (Chapter 4) based on the data that were collected the last time that lesson
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was taught. The supervisor has the ability to adjust mastery criteria and other details of how the software determines lesson phases. When the therapist is ready to begin conducting the lesson with the learner, the screen of the iPad resembles a standard discrete trial datasheet. At the top of the sheet is a notes section that is automatically updated with the latest notes that the supervisor entered into Skills for that particular lesson. In addition, Skills LogBook™ displays any notes regarding challenging behavior management that the supervisor has entered into the system. Each iPad is wirelessly connected to the central Skills server, so every time a lesson is conducted, the data are automatically and wirelessly updated in Skills. This gives the supervisor the ability to add notes for the therapist in real time from anywhere in the world with an Internet connection. At the time this manual goes to press, Skills LogBook™ is being used for internal purposes only, but it will be made commercially available in the near future.
CARE COORDINATION AND CASE MANAGEMENT A new development in autism treatment is the use of technology as a means for insurance agencies to carry out care coordination and case management. Using various treatment management software programs, of which Skills is one, insurance carriers are now able to allow their case managers to log into a learner’s account and view real-time progress, obtain reports, and, ultimately, make decisions about the learner’s future funding. The availability of this type of technology has been useful for increasing the ability of autism treatment agencies to communicate directly with insurance carriers and for care coordination to be carried out seamlessly. In the foreseeable future, once tens of thousands of learners’ assessments and curriculum progress are saved in databases and tracked using such software programs, the face of funding for autism treatment as we know it will likely change. That is, algorithms should emerge that are capable of using individual profiles to predict a learner’s potential progress within given treatment parameters. If this happens, the number of hours requested for funding should be generated directly from a computer program, eliminating the often arbitrary decision-making process of the funding agencies. If the analyses are based on valid data, then this would represent a shift toward data-based decision making on the part of funding agencies – something that is all but lacking today – while preserving the processes that enable families to challenge insurance carriers when necessary. Such computer programs should also allow funding agencies – and potentially consumers – to view quality rankings of autism treatment agencies in terms of their level of progress with the learners they serve in relation to other agencies and even among various clinical supervisors within the same organization. This should help improve the quality of
Training
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ABA service delivery as a whole by increasing accountability within the field and eventually weeding out the less effective clinicians, as their ability to obtain funding for their services will eventually be eliminated until they receive more training and demonstrate improvement.
TRAINING The need for global dissemination of expertise in ABA is great, and one of the largest bottlenecks is the availability of expert trainers. Web-based training is a promising method for addressing this need. Research comparing web-based training to in-person training for establishing clinical competence in ABA practitioners is still very much in its infancy, but the initial results are encouraging, both for training staff (Granpeesheh et al., 2010) and parents of children with autism (Jang et al., 2012). It seems unlikely that web-based staff training, no matter how sophisticated, will ever completely circumvent the need for human interaction in training, nor would we want it to do so. It seems likely, however, that web-based staff training will prove to increase the cost-effectiveness of disseminating staff training across longer distances and larger regions by reducing the number of hours of in-person training required and/or decreasing the number of in-person visits required by an expert trainer. A good model for incorporating web-based training is likely to be used as a replacement for some portion of classroom didactic training. In other words, it seems likely that some or all of the time that trainees would normally spend listening to a lecture in a classroom could be replaced by self-paced web-based training as long as it is followed by in-person performance feedback and on-the-job training. Technology-based trainings currently come in all different shapes, sizes, and modes of delivering content, including use of computer-animated videos; recorded human-delivered lecture with PowerPoint; narrated videos of procedures being carried out with learners; and interactive technology wherein trainees receive instruction and feedback while attempting to carry out procedures with a computer-animated learner.
Institute for Behavioral Training (IBT) CARD’s training materials for staff, educators, and parents are now available online in an eLearning format through the Institute for Behavioral Training (IBT; www.ibehavioraltraining.com). The format of the training is PowerPoint combined with videotaped lecture and examples of therapists demonstrating procedures with learners. These eLearning training modules are used all over the world by anyone interested in learning more about the delivery of behavioral intervention to learners with ASD.
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TELEMEDICINE The field of telemedicine is experiencing a rapid evolution in the utilization of technology to facilitate the practice of medicine across great distances. As a field, telemedicine essentially involves interacting in real time with a patient, provider, and/or caregiver via video or telephone conferencing or reviewing stored videos and patient data and includes diagnosing a problem and prescribing an intervention, as well as providing consultation to others who provide treatment. Although scientific evidence for telemedicine is still emerging, the world’s leading medical institutions now have satellite hospitals, and it appears that the use of telemedicine will only continue to grow. Telemedicine is useful in the delivery of behavioral intervention to geographically remote areas in which families would otherwise go without services. Some research has shown that it can be used to train individuals to carry out specific procedures for particular behaviors. The CARD Model uses telemedicine combined with in-person training and supervision in its Remote Clinical Services model. The iPads used for Skills LogBook™ (described above) can also be used to run live videoconferencing software, so supervisors in one part of the world can watch the therapist working with the learner and give live feedback. See Chapter 28 for more details on this model.
ABA BUSINESS MANAGEMENT SOLUTIONS In the field of ABA, most service provision agencies have been founded by clinicians providing services to individuals with ASD. However, as with any other business, many processes are required in order to effectively schedule sessions, track services rendered, submit billing, generate payroll, manage revenue, track training progress, and manage records. Technology now offers online management solutions for ABA agencies to use in conducting all of the above. While such solutions are currently in their infancy, this is an area that will likely progress quickly, resulting in streamlining the way in which ABA service agencies manage their business.
COMMUNITY OUTREACH The basic concept behind dissemination efforts – whether in the form of web-based training, such as that contained in IBT, or writing the book you are currently reading – is to provide information that empowers families living with ASD around the world to live better lives. Recent developments in web-based social networks and social media have shown the
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amazing power that technology has to bring people together and share ideas, if used effectively and with noble intent. Web-based networks and video-sharing platforms have transformed commercial, social, and political life in dramatic ways to the point where political and social revolutions can be sparked by the appearance of video content that deals with the right issues at the right time. Toward this end, CARD has actively participated in a number of technology-based community outreach efforts. For example, Dr. Doreen Granpeesheh hosted a monthly web-based radio show on Autism One Radio for several years called The ABA Piece of the Puzzle. Each monthly show provided practical information for parents and practitioners on one specific topic within ABA. More recently, CARD founded Autism Live, a web show (www.autism-live.com) that is broadcast live over the web, 2 hours per day, 3 days per week. The program is hosted by Shannon Penrod (autism mom, expert, and activist) and consists of live conversations with experts from a variety of fields relevant to ASD. In addition, Autism Live contains specialty features on a wide variety of topics, ranging from cooking, to vacations with children on the spectrum, to how to have more fun in your daily life. The purpose of Autism Live is to provide genuine hope by giving information that empowers families living with ASD to live fuller lives.
SUMMARY Technology is a powerful driving force in the future of autism treatment. While technology is currently being used in many ways to assist in the provision of services and training, the potential for future developments and their implications for the evolution of autism treatment are vast. The CARD Model values technology and is committed to leading the development of technology solutions that help achieve the mission of providing global access to top-quality treatment to as many families affected by autism as possible.