Case Illustrations

Case Illustrations Chris A 29-Year-Old Adult With Intellectual Disability

Sources of Information

Mother, Karen Jones

The clinician interviewed Chris’s supervisor, Michael Smith, during a visit to the vocational center. Chris was observed for 90 minutes while he was engaged with five other adults in a T-shirt sorting and packing job, and later during lunch.

Supervisor, Regional Vocational Day Center, Michael Smith

Background Information

Adaptive Behavior Assessment System, Third Edition (ABAS-3), Adult Form completed by:

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Stanford-Binet Intelligence Scale, Fifth Edition Woodcock-Johnson® IV Tests of Achievement Review of school, vocational, and medical records Behavioral observations at the Regional Vocational Day Center Interviews with client, parent, and supervisor

Referral Chris Jones, a 29-year-old male with intellectual disability, was referred for evaluation in order to better understand his current levels of achievement, adaptive behavior, and intellectual development, and to review and possibly change his intervention program. His parents, together with a supervisor from the Regional Vocational Day Center, requested current assessment data as well as help in developing an intervention program designed to increase Chris’s independence and improve his social behaviors. The publicly supported center provides assistance and on-site work programs, including training in daily living, social, and vocational skills, for adults with intellectual disability and other neurodevelopmental disorders. The clinician interviewed Chris and his parents, Karen and Joe Jones, during a home visit. The family conveyed information in an open and friendly manner. They reside in a rural area 20 miles from a town of 18,000. Chris enjoyed showing his yard and room. Chris’s father works irregular hours at an electric generation plant. His mother has not worked outside their home since Chris’s birth and has devoted most of her time to his care.

Case Illustrations

Chris’s mother reported no prenatal, perinatal, or postnatal complications associated with her pregnancy with him. At about 6 months of age, Chris appeared to have “spells” that were diagnosed, in part through an abnormal EEG, as petit mal seizures. At about the same time, Chris was diagnosed with hemophilia. Several medications have been tried in an attempt to control his seiz ures. However, the medications have had limited success, and he has continued to have seizures every 2 to 3 months. Chris is an only child, and his parents described their parenting style as “overprotective.” At age 4, Chris was enrolled in a private kindergarten. The school staff felt that Chris’s development was slow but within the normal range. At age 5, Chris entered a public kindergarten, was evaluated, and was placed in a special-education program for children with developmental delays. At age 7, he was reevaluated and qualified for a program for students with mental retardation (now intellectual disability). Throughout his public schooling, Chris received most of his instruction in self-contained special-education classes along with a few inclusive regular-education classes (e.g., physical education and art).

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Chris’s parents reported that his mother typically gets Chris up about 7:00 a.m. He eats breakfast and watches television before his mother drives him to the vocational center. He remains there from 8:30 to 2:00. His mother takes Chris to a community physical fitness program on Thursday afternoons. Following the program, they often shop and eat out. Chris typically spends evenings at home playing video games. He has his bath at 10:30. His bedtime varies depending on the shift his father works. Chris sometimes goes to bed as late as 2:00 a.m. when his father returns after working the late shift. Chris has no ongoing or regular peer relationships outside the vocational center. Children of family friends come to Chris’s home on occasion. Also, at the invitation of Chris’s mother, a 13-year-old boy who lives down the road visits Chris at home occasionally for brief chats about video games. Chris has some peer contact as a result of his attending local high school football games in the fall. However, none of these relationships can be considered strong and supportive. Chris left public school at age 19 and immediately began attending the center daily. Michael Smith, Chris’s supervisor at the center, noted that while Chris’s cognitive skills are limited, his behavior is not problematic, and that he complies with instructions and rules. Chris’s social engagements with other clients and with staff are limited and occur only when required during training and vocational routines. When he was observed at the center, Chris had no verbal interactions with other clients during work time, and he ate alone during lunch. The assessment of Chris’s cognitive abilities and achievement was conducted at the center. Chris’s test-taking behaviors displayed suitable levels of attentiveness, engagement, and cooperation. Thus, the cognitive test data reported below are considered to be a valid indication of his abilities. Moreover, they are consistent with prior assessment data.

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Assessment Results Intellectual abilities: Chris’s general intellectual ability, as assessed by the Stanford-Binet Intelligence Scale, Fifth Edition, is at the 1st percentile, with a Full Scale IQ of 40. His standard scores are 55 on visual–spatial processing, 50 on knowledge, 46 on working memory, 45 on fluid reasoning, and 42 on quantitative reasoning. All are at the 1st percentile. Among these five abilities, Chris’s visual–spatial processing ability is more advanced than his quantitative reasoning. Achievement: Chris’s achievement, as measured by the Woodcock-Johnson IV Tests of Achievement, is consistent with his intellectual abilities and well below average compared to other adults his age. Chris’s cluster standard scores, 52 on reading and 46 on mathematics, are at the 1st percentile. Adaptive behavior and skills: Chris’s adaptive skills were assessed using the ABAS-3 Adult Form. Chris’s mother and supervisor each completed this form. Chris’s scores are reported in Table 3.3. Chris’s General Adaptive Composite and Conceptual, Practical, and Social adaptive domain standard scores are below the 1st percentile and consistent with his intelligence and achievement. His mother and supervisor report the need to provide mild to moderate levels of adaptive behavior support at home and the center, such as assistance with selecting appropriate clothes, reminders to respond verbally when others speak to him, all forms of meal preparation, and household cleaning. Thus, the data support a continued diagnosis of intellectual disability. Most of Chris’s adaptive skills are also in the extremely low range, with no significant strengths and weaknesses in the profiles of adaptive skill area scaled scores completed by the mother or supervisor. Additionally, there are no significant differences between the scores from the mother and supervisor.

Chapter 3 Interpretation and Intervention

Table 3.3. ABAS-3 Adult Form Scores for Chris: A 29-Year, 6-Month-Old Adult With Intellectual Disability ABAS-3 GAC and adaptive domain standard scores (M = 100, SD = 15) Mother’s score GAC/Adaptive domain

Standard score with 90% confidence interval

Supervisor’s score

Percentile rank


Percentile rank

General Adaptive Composite (GAC)

52 (49–55)

0.1

52 (49–55)

0.1

Conceptual domain

57 (52–62)

0.2

57 (52–62)

0.2

Social domain

61 (56–66)

0.5

61 (56–66)

0.5

Practical domain

51 (46–56)

0.1

52 (47–57)

0.1

ABAS-3 adaptive skill area scaled scores (M = 10, SD = 3) Adaptive domain and adaptive skill area

Mother’s scaled score

Supervisor’s scaled score

Communication

3

2

Functional Pre-Academics

1

2

Self-Direction

1

1

Leisure

3

2

Social

1

2

Community Use

1

1

Home Living

1

1

Health and Safety

2

3

Self-Care

1

1

Conceptual domain

Social domain

Practical domain

Case Illustrations

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Interventions Chris’s parents acknowledged that the development of his adaptive skills has been constrained by their desire to shelter him and to personally provide for his daily needs. For example, his parents said they have never encouraged Chris to spend time with peers by himself, and that his few social interactions have been under their supervision. They stated that they have never expected Chris to follow time lines or take initiative to do things on his own. However, they expressed their belief that, with training, Chris could perform more independently. These types of skills can now be addressed through attention to his adaptive skills. The ABAS-3 data supported that belief of Mr. and Mrs. Jones and motivated a commitment to an intervention plan leading to increased independence. A meeting with Chris, his parents, and his vocational center supervisor helped identify specific long-term behavioral goals. These included the need to prepare Chris for work in a location other than his current restricted center placement and to live in an intermediate-care facility when his parents are no longer able to care for him.

Chris and his caretakers agreed that he needs to rely on himself to wake up in the morning. They therefore determined to teach him to set and rely on an alarm clock rather than his mother. Additionally, Chris eventually will live in a group home and be required to socialize with peers. However, he does not currently seek friendships. To help Chris engage with peers, his parents and supervisor developed interventions to encourage his social skills development. For example, social skills will be taught during his lunch period. Finally, Chris’s work style is highly dependent on directions from his supervisor and others. His supervisor agreed to institute an intervention designed to help Chris develop more independent work habits. For example, Chris will be encouraged to work by himself on tasks that his supervisor considers within his range of emerging skills. His supervisor will provide training and support as needed, along with assuring Chris that he is able to perform the desired tasks. His supervisor will praise and reward Chris financially for completing those tasks independently.

Chris’s parents and supervisor agreed that his limitations should be viewed in light of his current and emerging adaptive skill needs. They decided to focus on those skills that Chris needs to use daily now and in the future, are considered important and thus valued by his caretakers and Chris, and can be sustained through daily practice over time. The ABAS-3 Intervention Planner was used to help identify intervention tips for Chris’s priority needs. Three examples follow.

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Mary A 3-Year, 4-Month-Old Child With Autism Spectrum Disorder

Sources of Information Adaptive Behavior Assessment System, Third Edition (ABAS-3)

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Parent/Primary Caregiver Form completed by mother, Anita Teacher/Daycare Provider Form completed by Lane Lopez, teacher, supervisor, Community Autism Center

Autism Diagnostic Observation Schedule™, Second Edition (ADOS™-2) Bayley Scales of Infant and Toddler Development®, Third Edition Clinical Evaluation of Language Fundamentals®–Preschool-2 Fine motor evaluation by occupational therapist Behavioral observations at Community Autism Center Review of autism center and medical records Interviews with mother and teacher

Referral Mary first received a diagnosis of autism spectrum disorder at age 2 after an evaluation by a university autism program. Now age 3 years, 4 months, she was referred by her parents for the current evaluation. It included an assessment of her adaptive behavior and cognitive, language, and motor development. The purposes of this assessment are to describe Mary’s development in these areas, assist in program planning at her home and a community autism center, establish baseline data needed to monitor her progress, and inform transition plans for her enrollment in a public school prekindergarten program next year.

Background Information Mary lives with her biological mother, stepfather, 14-year-old stepsister, and 65-year-old maternal grandmother. Mary’s mother owns a financial consulting business. Her stepfather is employed as manager of a local pharmacy. The flexibility of the parents’ jobs, along with the availability of the grandmother, allow an adult family member to

Case Illustrations

always be with Mary outside of her participation at the community center. Mary was born full-term, of average length and weight, and, except for a C-section, the delivery was normal. Her mother was 27, in good health, reportedly consumed no alcohol or illegal drugs during her pregnancy, and smoked about eight cigarettes a day. Mary’s early gross motor development generally was normal. For example, she sat up at 7 months and walked at 12 months. She displayed oral/ sensory sensitivity from infancy. Recently, she has refused all but a limited range of foods (e.g., peanut butter and jelly sandwiches, grilled cheese sandwiches, toast). She eats with her hands and smells her food before eating it. Mary is not fully toilet trained. Mary attends an intensive day-care program on weekdays at a community program for children diagnosed with autism spectrum disorder. Her teacher reports considerable improvement in Mary’s behavior and achievement during the last 6 months, following implementation of applied behavior management principles. In addition, Mary is beginning to exhibit parallel play, an ability considered to be a precursor to the development of more advanced social skills. Her parents report that Mary displays no fears and shows minimal awareness of danger at home. They both describe her as “bouncing off the walls,” displaying potentially dangerous behaviors (e.g., climbing on top of the TV), almost always in action, and able to sustain her active behavior over a long period of time. When told “no” at home, Mary runs, throws tantrums, bangs her head, twirls, kicks, and hits. In contrast, her teacher reports that Mary does not throw tantrums at the autism center. There are no reports of serious injuries, illnesses, allergies, or problems with visual or auditory acuity. She takes medication twice daily to improve concentration and attention. Mary typically goes to bed at 8:00 p.m. and sleeps through the night without nightmares.

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Her parents and teachers agreed that Mary enjoys placing objects (e.g., blocks, magnets, colors) in a line, spinning toys, and watching television programs that present captioned information at the bottom of the screen. Mary does not interact with family members, has no neighborhood friends, and displays limited interaction with peers in her autism program.

Assessment Results Adaptive behavior and skills: Mary’s mother completed the ABAS-3 Parent/Primary Caregiver Form, and her teacher completed the ABAS-3 Teacher/ Daycare Provider Form. Scores are reported in Table 3.4. ABAS-3 ratings from Mary’s mother and teacher generally are consistent. Her mother’s and teacher’s ratings indicate that most areas of Mary’s adaptive behavior are in the extremely low range as reflected in scores from the General Adaptive Composite, the three adaptive domains, and eight of the ten adaptive skill areas. However, ratings from both her mother and teacher suggest that Mary’s relative strengths are found in her Functional Pre-Academic and Motor adaptive skill areas, compared to her extremely low adaptive functioning in other skill areas. Ratings from both her mother and teacher indicate that Mary’s Motor adaptive skills are in the below average range, and an inspection of their item ratings suggests that Mary’s gross motor skills are more developed than her fine motor skills. Mary’s Functional Pre-Academic adaptive skills, as rated by her mother, are in the low range. In contrast, at the autism center, Mary’s Functional Pre-Academic adaptive skills are rated by the teacher as being in the average range. Autism spectrum disorder: Behaviors associated with an autism spectrum disorder were assessed through the use of the Autism Diagnostic Observation Schedule™, Second Edition (ADOS™-2). Mary was administered Module 1 of the ADOS-2, as this module is designed specifically for children who are 31 months of age and older and who are pre verbal or using single words. Mary was quite active during the assessment and seemed to enjoy exploring the toys and materials, though she showed little interest in interacting with the examiner and did not exhibit pretend play. For example, although she was not receptive to the

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examiner’s attempts to engage her during the Free Play activity, she actively explored the materials by pressing buttons repetitively on cause-and-effect toys, spinning the wheels of the toy car, and engaging in sensory examination of the objects such as lining up the toy silverware, peering at it out of the corner of her eye, and then smelling it. During the pretend birthday party, she did not display interest in the doll or the party, though she did seem to enjoy placing the pretend candles into the birthday cake. Mary did not approach the examiner or her mother to communicate during the assessment; for example, she did not request help or show or share objects. Mary’s Overall Total score on the Module 1: Few to No Words algorithm (selected for children who use fewer than five words during the session) exceeded the autism cutoff and was consistent with an ADOS-2 classification of autism. Her ADOS-2 Comparison Score further indicated that, on the ADOS-2, she displayed a high level of autism spectrum–related symptoms as compared with children who have autism spectrum disorder and are of the same chronological age and language level. These results support a continued diagnosis of autism spectrum disorder. Cognitive and language development: Mary’s development was assessed with the Bayley Scales of Infant and Toddler Development, Third Edition. Mary’s cognitive and motor composites of 76 and 80, respectively, are in the low to low-average range. However, her language composite of 60 is extremely low and below the 1st percentile. She displayed little meaningful language during the assessment, an indication that her speech and language development are delayed. She does not engage in conversation with others. When speaking, her words are unrelated to questions or comments made by others, or to the nature of her activities. Given the importance of language to early development, including the development of children with autism spectrum disorder, Mary’s language also was assessed by a speech–language pathologist using the Clinical Evaluation of Language Fundamentals–Preschool-2. Her core language standard score, as well as receptive and expressive language indexes, were again extremely low (at or below the 1st percentile). Her language development is similar to that of toddlers between 16 and 20 months of age.


Table 3.4. ABAS-3 Parent/Primary Caregiver and Teacher/Daycare Provider Scores for Mary: A 3-Year, 4-Month-Old Child With Autism Spectrum Disorder ABAS-3 GAC and adaptive domain standard scores (M = 100, SD = 15) Parent/Primary Caregiver Form GAC/Adaptive domain


Percentile rank

Teacher/Daycare Provider Form Standard score with 90% confidence interval

Percentile rank

General Adaptive Composite (GAC)

55 (51–59)

0.1

58 (56–60)

0.3

Conceptual domain

57 (51–63)

0.2

67 (63–71)

1

Social domain

51 (44–58)

0.1

51 (47–55)

0.1

Practical domain

53 (48–58)

0.1

53 (49–57)

0.1

ABAS-3 adaptive skill area scaled scores (M = 10, SD = 3) Adaptive domain and adaptive skill area

Parent/Primary Caregiver Form

Teacher/Daycare Provider Form

Conceptual domain Communication

1

1

Functional Pre-Academics

5

10

Self-Direction

1

2

Leisure

1

1

Social

1

2

Community Use

1

—

Home/School Living

1

2

Health and Safety

2

2

Self-Care

1

2

Motor

6

7

Social domain

Practical domain

Case Illustrations

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Fine motor: An evaluation by an occupational therapist indicated that Mary displays delays in fine motor, self-care, and play skills along with decreased attention, limited communication, and sensory integration. Her gross motor skills, including mobility, were relative strengths.

Interventions Mary’s parents and teacher agreed that her skill development and program implementation must focus on developing more control of her behaviors (e.g., running, head-banging, twirling, hitting, kicking) at home. The use of applied behavior management principles at the autism day-care program has resulted in important behavioral improvements there. Mary’s mother, father, and grandmother agreed to be trained in the use of applied behavior management principles and to work with the school psychologist to implement a similar program at home. Mary’s parents and teacher discussed current and emerging adaptive skill needs. They are especially concerned about preparing Mary to transition to a public preschool program. Mary’s current program is producing positive results. However, parents and teacher agree that combined home and school intervention efforts that further promote communication, social, and self-care skills are needed. Information from the ABAS-3 Intervention Planner was used to help identify intervention strategies. Some examples follow. In reference to communication skills, receptive language typically precedes expressive language. Consistent with suggestions from the ABAS-3 Intervention Planner, Mary’s parents and teacher agreed to verbally label common objects or events in Mary’s environment as they occur (e.g., washing hands, dressing, toileting) to promote receptive language. They then will prompt her to repeat the words to facilitate expressive language. Rewards will be contingent on successful prompting. The goal is for Mary to label 10 or more new objects or events weekly.

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In reference to social skills, Mary has not initiated social relationships with peers. At times, young children with autism spectrum disorder are willing to engage with others who show curiosity about these children’s unusual interests. Thus, others need to initiate relationships for Mary. As suggested by the ABAS-3 Intervention Planner, at school, the teacher will encourage a connection between Mary and high-performing children with autism by assigning a common task to them (e.g., to color a page or to build with blocks). Also, the teacher will identify an older student to engage with Mary in common activities once or twice weekly. The teacher will gradually encourage Mary to play with other children by having her try different activities within the program. Similar efforts are needed at home. The parents agreed to involve Mary’s older stepsister and grandmother in similar efforts to interest Mary in social interaction. In reference to self-care skills, students in the public prekindergarten program are expected to use the restroom by themselves. Mary has not achieved this important developmental milestone and needs to do so before beginning the public school program next year. The ABAS-3 Intervention Planner provides suggestions for promoting behaviors that, in succession, can result in completed toilet training. Efforts begin by encouraging behaviors that occur at the end of the toileting cycle (e.g., flushing the toilet) and successively work backward to include earlier skills (e.g., throwing the toilet paper in the toilet, wiping with toilet paper, pulling toilet paper off the roll, pulling clothes down). Coordinating interventions at home and school is critical to improving self-care and other adaptive skills.


Other Examples These two brief case illustrations provide examples of the use of the ABAS-3 with an adult with intellectual disability and a young child with autism spectrum disorder. Indeed, adaptive skills are important for everyone, especially those who display various types of limitations, disabilities, problems, or needs. Adaptive skills should be assessed routinely for children or adults who have difficulties, disabilities, or disorders that may interfere with daily functioning, as part of comprehensive assessments for evaluating strengths and limitations, diagnosis and classification, or identifying needs for services and support. Additional examples of uses of the ABAS-3 include the following:

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The parents of a 4-year-old child request assessment by school psychologists because the child has not met major developmental milestones.

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A fifth-grade student diagnosed with ADHD is referred to a mental health center for comprehensive assessment, based on reports of diminished self-direction, self-care, and school/home living skills.

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A school district collects assessment data to assist and monitor high-school students with disabilities in their transition from school to work settings.

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An occupational therapist is responsible for coordinating the rehabilitation of a young adult with traumatic brain injury.

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A speech–language pathologist routinely conducts evaluations to better understand adult clients’ development and use of communication in social and daily living activities in home, school, and work settings.

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An early intervention specialist in a public health clinic evaluates a 1-year-old child with cerebral palsy. A school district requests adaptive behavior assessment to assist in planning and coordinating home-school programs for children with special needs. A fourth-grade student diagnosed with an emotional disturbance displays various social and self-direction problems at home, for which the parents have requested help from a psychologist in independent practice.

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Parents of a child with a visual impairment request consultation with a school’s Individual Education Plan (IEP) committee on home interventions for adaptive skill development.

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A third-grade student with a learning disability is referred to the school psychologist because of problems in daily behaviors and practical skills.

Other Examples

An assisted living facility uses assessment data to help clinicians make decisions regarding program planning and monitoring of residents’ self-help skills. The family of a person with Alzheimer’s disease requests that a community agency conduct an evaluation to help improve functional behaviors and skills of daily living. A social worker evaluates people with depression and anxiety to assess effects of the mental disorders on daily functioning.

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A psychiatrist assesses a person to monitor changes in daily behaviors in response to medication.

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For more examples of adaptive behavior assessment and intervention, see Oakland and Harrison (2008).

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