Educational Treatments for Autism Spectrum Disorder

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Educational Treatments for Autism Spectrum Disorder
Characteristics of Autism Treatments Not all therapies work for every child with autism, Asperger Syndrome or PDD-NOS. Each child on the autism spectrum may not have the same characteristics, but even children with similar characteristics may not respond to the identical therapies or treatments. According to Laura Schreibman, a psychologist who is the director of the Autism Research Program at the University of California, San Diego, and the author of “The Science and Fiction of Autism” (Harvard University Press, 2005), if anything definitive can be said of the popular therapies for autism, it is that treatments have to be individualized. What works to reduce symptoms in one child may or may not help another. Families need to know the basic characteristics of each therapy or intervention and match their child to an appropriate intervention and be willing to evaluate their child’s progress during treatment. Applied Behavioral Analysis (ABA) Philosophy: ABA is based on the principles of behavior originally described by B.F. Skinner in the 1930’s. For example, the principle of positive reinforcement (consisting of following an acceptable action by a reinforcement or reward) has been used to develop a great variety of skills for people with and without disabilities. Intense behavioral interventions for young children with ASD, following the lead of Ivan Lovaas in 1987, have been shown to improve speech and language skills, learning skills, and also play and social skills. Many problem behaviors have been reduced or eliminated in people with autism using applied behavioral principles. Direct observation and data collection are strong components of ABA. Classic ABA may consist of teacher directing specific structured questions to the child; and the child responding and being reinforced. This specific type of ABA is usually called Discrete Trial Training.

A Look at the Program at Work: A behavior consultant usually evaluates the child’s skills and devises a program to teach needed skills (as basic as sitting in a chair for 30 seconds) by breaking down those skills into many component steps that can be taught and reinforced immediately. The parent, consultant and therapist usually come up with a list of things the child likes that may be positive reinforcers. Lovaas initially devised a program of 40 hours a week of intense therapy, punctuated by frequent breaks and positive reinforcements. Trained local therapists, working from the behavioral consultant’s plans, usually conduct treatment. Parents are also trained in behavioral principles so that the child can be trained consistently throughout his or her day. Therapist (getting attention and holding two objects in front of child): “Show me book. (Or “Touch book”) Child touches the book Therapist: “Right, you touched the book.” Therapist gives the book or another reinforcer (could be food at first) to the child. If the child responds incorrectly or does not respond, the teacher gives additional assistance in the form of prompts. Therapist gives the child many more opportunities to do the task successfully. Pros: Research-based positive results: Frequent research studies conducted with young children on the autism spectrum (receiving early, intense ABA instruction on a one-to-one basis) have shown scientifically validated effective intervention. Lovaas (1987) published a study that found that 47% of the children receiving early intensive ABA were able to function successfully in general classrooms. Another 40% made substantial improvements but continued to need some specialized intervention; and about 10% made minimal gains. These findings have since been replicated in a number of studies including: Fenske et al (1985), Anderson et al (1987), Smith et al

(1997), Smith et al (2000), Bibby et al (2001), and Eikeseth et al (2002). Howard et al (2005) examined 29 children receiving intensive ABA (25-40 hours per week) as compared to 16 children receiving 30 hours in an "eclectic" education classroom. The results show that the children receiving ABA got better scores than the children in the eclectic group in the areas of cognition, non-verbal and verbal language. The only area that showed no significant difference was in motor skills. Cons: Not a cure Children with autism can be successful in general classrooms, but not be cured of autism. Some professionals have been quoted as saying that ABA cured almost half of the children in Lovaas’s study. Parents have been given unrealistic expectations of a cure for autism through ABA. Time The time required by the classic ABA early intensive therapy could be a major disruption to the child’s family. Trying to give 40 hours a week therapy or introducing and scheduling various therapists for 6-8 hours a day can be very disruptive to family life. In addition, typical children between the ages of 2 ½ and 5 do not have demands put upon them to work for the amount of time required to do classic ABA therapy. Cost The cost of consultation from the professional behavior consultant, along with the cost of 40 hours of therapy per week can be between $33,000 – $40, 000 for one year. The average length of therapy is 3 years. Some families get financial help from Medicaid waivers (depends on the state), some private insurances cover some of the fees, and families are putting pressure on legislatures to have a clause requiring treatment for autism in all company insurance policies. Generalization Some children taught by ABA have a difficult time applying the skills they have learned to real world situations. This generalization has to be integrated into the behavioral training. Changes in locations, people doing therapy, variety of

objects being used and the various prompts used for assistance need to be part of the intervention. ABA-based Interventions Pivotal Response Treatment Philosophy; Pivotal Response Treatment (PRT) is based on the applied behavioral therapy principles listed in the above ABA discussion. However, the treatment is integrated into the child’s everyday activities. Drs. Robert and Lynn Koegal at the University of California, Santa Barbara, developed PRT from a program called Natural Language Paradigm. The Koegels felt that the list of skills needed and behaviors that needed to be modified was too overwhelming for treatment. They felt that certain pivotal behaviors could be taught that would enable the larger areas of communication, play, social skills and self-monitoring to be improved. Motivation An important pivotal response is motivation. Many children with autism seem to lack motivation to learn new tasks, comply with instructions, pay attention to people and attempt to leave teaching situations either by physically moving away or by withdrawing into themselves and not responding to the teaching. Several studies have shown significant improvement in communication and attention (Laski, Charlop and Schreibman, 1988; R.L. Koegel, O'Dell, & Koegel, 1987) when their motivation has been increased. Motivation is often increased if the stimulus items (toys, etc.) are highly desirable and chosen by the child and not by the clinician or parent. Another study discovered that varying the tasks motivates the children to respond better (Dunlap & Koegel, 1980). It is sometimes difficult to find reinforcers for children with ASD; however, effective reinforcers must be found to motivate them to learn. Responsiveness to multiple cues Children with autism may not attend to multiple cues in a situation. For example, when the teacher points at a dog and says, “Dog,” if the child only sees the visual cue of a real dog, but does not hear or process the word dog, he will

not learn the label. Typical children will use the sight of the dog, the hearing of the label and perhaps tactile cues from touching the dog to help them make the association of the word with the object. This selective attention called stimulus overselectivity can seriously impede a child’s learning and generalization of learned skills. Child directed As mentioned above, children with ASD (and others too) respond better when the skills they need to learn are part of an activity that they have chosen. Integrating learning into natural situations also makes generalization more possible. The therapist or parent can structure the situation so that the child will come in contact with the object or toy, but the adult must follow the child’s cue. A Look at the Program at Work: Anna’s mother notes her interest in the foods as she prepares dinner. She puts some of the things that she knows are Anna’s favorites almost within her reach. Anna (reaching toward the piece of apple): “Appo”. (Response) Mother gives he the piece of apple and says: ”You want apple.” (Consequence) Pros: Most parents and therapists feel more comfortable with teaching skills in more natural situations than are done with formal ABA training. Most children feel more comfortable with learning informally as done in PRT. There is probably less problem with generalization when the skills are taught in context. Time: The therapist or parent needs to give the child many, many opportunities within the day to practice the skills he is to learn. However, since many of the opportunities are part of daily living, not as much of the dedicated therapy time takes time out of the parent’s or the child’s day. Generalization: The usefulness of the learned skills should be quite apparent since the skills are taught in daily life situations to begin with. Attention will still need to be paid to using the skills in different situations and with different people. Cons: Training:

Getting training in PRT may not be easy in some parts of the country. The books are very clear, but it is difficult to learn the skills without modeling and supervised practicing. Cost: Depending on how much time the parents can spend on PRT, the therapist’s time and cost is the major expense. The Autism Center at Santa Barbara gives screenings, does research and trains professionals or college students. The books which detail the system are relatively inexpensive, but trained therapists, teachers or parents may be difficult to find, depending on the area of the country. Difficulty: The parent or therapist must keep the objectives of the child’s plan currently in her mind, so that she can capitalize on the teachable moments that the child presents. This may especially difficult if the teacher or therapist is responsible for several children. Research At the present time, not much research has done on PRT except for the Koegels and other faculty and students at Santa Barbara. Research that has been done showed positive results from using PRT. Picture Exchange Communication System (PECS) PECS is a form of augmentative/alternative communication (AAC) that uses pictures instead of words to help children communicate. Usually

Boardmaker symbols , i.e. squares.

are used in a book or on small cardstock

Parents and professionals have observed that children on the autism spectrum may learn words, but use them only to answer adult questions. To be truly useful, children have to be able to initiate language. PECS teaches a child to initiate language to receive what he wants as a consequence. PECS is based on applied behavior analysis (ABA) where prompts are given to guide the child to

exchange a picture for the real object. PECS is usually taught in six phases. In the early phases of PECS’s training, the child chooses a picture of a desired food, and receives the food in exchange for the picture. At this stage, it takes two teachers or therapists to prompt the interaction, one behind the child to prompt picking up the picture and the other as a communication partner who gives the item pictured and labels it vocally. Then the picture is moved farther away so the child must move to obtain the object. In later phases the child gives the picture in response to a question by an adult and as part of a complete sentence. A Look at the Program at Work Phase One: • The teacher puts a favorite food (may be under a clear plastic cover) on a table near the student. • • • • • Pros: Communication A nonverbal child can begin to communicate his desires even if he is having difficulty with speech. Often behavior problems become less difficult because the student can communicate his desires, instead of communicating with bad behavior. Initiation of Communication The student learns to begin communication because he wants something, not only as an answer to an adult question. Studies have shown that initiations have generalized to daily life also. Several research studies found that children using of PECS made more communicative attempts than controls. One study The teacher may draw the student’s attention to the food, but does not speak. The facilitator behind the child directs the child’s hand to the picture and has him hand the picture to the teacher. The facilitator immediately gives the object that matches the picture to the student. The teacher says,” Oh, you want the cookie. You may have it.”

found that almost one-half of the children stopped using PECS and started using natural speech within a year. Social Skills Children with autism often have difficulty approaching peers socially. In the case of PECS’s use, the child is not expected to speak when approaching someone so the initiation may be less intimidating to him. Handing someone a picture can be physically prompted, while verbalizations cannot so PECS may be easier to teach. Adults and children are usually able to figure out what the Boardmaker icon symbolizes as contrasted with the few people who know signing. Costs: The cost for the materials used in PECS are relatively inexpensive, especially if there are several children involved. The Boardmaker computer program can cost $330 or more, but it can be used for any number of children. Each student needs a binder to store the icons, cardstock, Velcro and access to laminating. Cons: Teacher Time The use of two teachers or adults during the early PECS phases does require an investment in teacher time. Also, if the teachers have several students on PECS, keeping track of the PECS squares can be complicated and messy. A possible barrier may be that because many teachers are acquainted with Boardmaker symbols, they don’t go through the necessary steps to really use PECs in phases as described above. Teachers can say, “I have used PECs and it didn’t work,” while they have just used symbols for the words the child does not know. Curriculum PECS is a form of communication, not a whole curriculum for students with autism. The task analysis of teaching and learning PECS can be quite formal and stilted.

Structure-based Programs
TEACCH – Training and Education of Autistic and Related Communication

Handicapped Children STACK (Ohio’s version of TEACCH) TEACCH is a program established by Eric Schopler and his colleagues at University of North Carolina in the late 60’s. At the time of its development, autism was said to be caused by “refrigerator mothers” that failed to give emotional support to their children. The TEACCH program had a philosophy that was very different from the prevailing thought. Parents were not to blame for their children with ASD, but they played a crucial role in the treatment for their child. In addition, children with autism would be able to learn if they were taught in a structured manner using their visual skills. The classroom part of TEACCH is used in the state of North Carolina as their primary method of working with students with ASD and is frequently called Structured Teaching. Reference The principles of Structured Teaching include: • • • • Understanding the culture of autism. Structuring the physical environment. Using visual supports to make the sequence of daily activities predictable and understandable. Using visual supports to make individual tasks understandable. The student enters the classroom and consults his visual schedule that lists the subjects or classes, frequently symbolized as pictures that make up the classes or tasks that he must do that day. The symbols may be attached to the schedule with Velcro and the student may put them away in a pocket when the task or class is complete. His schedule will probably be the same every day or adjusted for special classes such as physical education, which are not taught every day. . A Look at the Program at Work

The tasks that he does are often arranged in some kind of box lid or container that shows him exactly what to do - from left to right.

TEACCH also does social skills training and vocational training for the students.

PROS:
TEACCH has been successful in North Carolina for almost 40 years. Training for teachers is available from the university and from other satellite centers and from the Educational Service Center of Central Ohio, usually in the summer. TEACCH’s website states that over the last 40 years, only 5% of TEACCH’s adult clients have had to be institutionalized – compared to an average of 46% nationally. Some research studies have shown that TEACCH clients have made substantial gains over the control groups of students

Reference
The fact that TEACCH includes social skills and vocational training is a plus as far as the skill deficits of autism are concerned.

CONS:
Research studies usually have small numbers of students that make it difficult to generalize. Many studies do not have control groups. More large-scale studies with quality standards need to be run.

Teacher Time

It is not always clear what skills the student is to learn. He or she learns the structured process of solving a task, but it depends on the teacher what the content of the tasks actually are. With the growth of standards-based instruction, many grade-level indicators will be difficult to make into a task TEACCH-style. TEACCH is intensive for the conscientious teacher. It usually involves making a lot of work tasks and cuing them to subjects that are parts of the general education curriculum. In addition, the heavy emphasis on visual schedules, charts and Boardmaker symbols takes a good amount of nonteaching teacher time.

Relationship-based Programs
DIR/Floortime Model – Greenspan & Welder Communicating Partners – James MacDonald Philosophy: The DIR initials stand for the Developmental, Individual-Difference, Relationship-based model developed by psychiatrist Stanley Greenspan and psychologist Serena Weider to support individuals with autism disorders. Floortime, the common name, comes from the practice of playing with the young child on the floor being guided by the child’s play interests and developmental levels in order to develop a relationship between the child and parents or other adults Greenspan and Weidner (2006)propose that typical children go through at least 6 stages of relating to others. 1. Attention (ability to stay calm and observe the world around him). 2. Engagement (emotional connection) with parents and other caregivers 3. Turn-taking and joint regard (emotional connections to partners’ signals, etc. “Look at that big thing.” (adult pointing, child looking where adult points.) 4. Joint problem solving (child uses adult to get something). 5. Pretend play 6. Connecting ideas (logical thinking)

Families and teachers are taught to intervene based on the child’s current developmental level stage. James MacDonald’s ECO or Communicating Partners Program (Ohio) is also based on following the child’s lead, playful interactions, turn taking and joint regards. He, however, emphasizes parent interaction more intensely than Greenspan. He advises the parents to wait expectantly for the child to respond, to encourage physical and sound imitation, and to make the parent the child’s most exciting toy. He also gives many examples of sharing control with the child by playing games where the child can tell or gesture the adult to do something. A Look at the Program at Work: The child will be assessed in a natural type setting so that his interests and developmental level (social and emotional) can be obtained. An individual program will be developed for him and usually his parent. The parent then plays with the child at the accessed developmental level, following the child’s lead. When trust is accomplished, the parent may be challenged to engage the child at a higher level – still done in a playful manner. The parent watches the child lining up MatchBox cars on the floor. She hands the child one of the cars for him to line up (signaling that she wants to play.) The mother says, “Here,” as she hands him the car. The child places the car into his line. The mother picks up another car, hands it to the child, saying, “My turn.” If the child continues to take the car and put it into a line, the mother says, “Yes, your turn RRRRR” The mother tries to set up a turn taking situation with motor actions that may be transferred to a verbal turn taking (RRRR sound). Later the mother may block the child from taking any more cars, hoping for him to initiate a gesture or sound or word to make her barrier disappear.

Time

The parents are asked to do from 6 to 10 Floortime sessions daily, each session lasting 20-30 minutes each. The child may also require 3 15 minute running, jumping and spinning sessions. The parents may also be urged to have 4 or more play dates with typical children a week. Other therapies may be added to the home program such as speech and language. Most professionals and parents find this time commitment quite intensive. The Communicating Partners program does not tell the parents the time they must spend working with the child. In fact, many examples are given of working the principles into the daily tasks of the family. Cost DIR has available an online course ($175), other trainings and books ($15 and up) for the parent or other support person. There are 3 sets of DVDs that can be used for teaching the adult facilitators (about $90 per set). Greenspan also holds training sessions at his facilities. Parents have said, however, that with the book, Engaging Autism (Greenspan, 2006) many parents can set up their own program. Because this therapy is so individualistic, based on the child’s interests and preferences, specific lessons are not given that may make it difficult for the parent to plan the many encounters. Communicating Partners offers at least two books available to parents, Play To Talk: A Practical Guide to Help Your Late-Talking Child Join the Conversation (MacDonald & Stoika, 2007), and Communicating Partners: (MacDonald, 2004) for between $20-25. Dr. MacDonald also has a Yahoo group where parents and professional discuss this program and MacDonald frequently comments. He also does consulting, but essentially this program is very low cost. It differs from Greenspan in the amount of practical suggestions and help it affords to parents. Pro: Greenspan and MacDonald focus on the social, communicative and emotional interactions of parents and child with ASD. Many families are more comfortable with this approach and the resulting climate in the home than with more behavioral approaches. Very young children can respond to the play

interactions, and it appears closer to the actions of typical children. Both the Floortime and the Communicating Partners programs can be used with other approaches that focus more on educational issues. Cons: Greenspan’s program, as outlined, is very intensive and time consuming for the family. MacDonald did not specify the amount of time that should be spent each day, but one of his research studies found that the parents spent about two hours per day on the program while the study was being conducted. Research The type of educational research conducted on both of these programs was qualitative, rather than quantitative with control groups. Without studies using generally accepted scientific methodology, professionals feel that “there is no adequate research evidence that interventions based on the DIR (Floortime) model are effective for treating autism in young children” Report of the Guideline Recommendations: Autism / Pervasive Developmental Disorders Assessment and Intervention for Young Children (New York State Department of Health, 1999). Many anecdotal accounts from parents, however, laud this relationship approach.

Relationship Development Intervention (RDI)
Philosophy

“The goal of the RDI Program is to provide the majority of people on the
autism spectrum with the potential to attain a true quality of life,” (Gutstein, 1995) Gutstein believes that programs that teach social skills often focus on superficial skills such as how to approach another child playing on the playground, and rarely go far enough to teach the real skills needed to develop friendships or manage in the adult world. Connections Center, the name of his intervention center, provides ways to address the core deficits of autism: Rigid thinking, aversion to change, inability to take another’s perspective and “black-and-white” thinking. Gutstein and Sheely (Gutstein’s wife) have set up a set of stages that are based on how a typical child develops relationships. Each stage has a series of

exercises or social games that are done with the child and parent which are described in considerable detail. Stage 1 is emotion-sharing; Stage 2 is referencing; Stage 3 is coordinating actions, Stage 4 is using language and nonverbal communication; Stage 5 flexible thinking and problem solving and Stage 6 is co-regulations using past and anticipated information. The student is given a name such as Navigator describing the Stage he is experiencing. A Look at the Program at Work: Dad and his daughter are transferring straws from a box into a dispenser. Dad does not give instructions for the task but comments positively on the child’s attempts at the task. He helps her to see that there are different ways to do the task – some faster than others (helping flexibility). Another mother makes muffins with her child, taking turns with stirring, and with the mother commenting on the activity.

Pros:
The books, DVD’s, many video clips and consultations give the parents ample direction to work with their children – far more than Floortime. The program has many activities and is flexible enough to meet the needs of most children on the autism spectrum. It also develops more than surface social skills and works on relationships that address the quality of human life. Parents who have the time and resources often find the therapy with their children creative and fulfilling. They can see the progress of their child as they work with him or her. Often they develop a more loving, social relationship with their child. Cons: Time and Cost The time demanded by RDI is very intense. RDI can also be very expensive. The books and DVD are reasonable in price, but the training for parents – 2 days for introductory principles and 4 days for more extensive workis very expensive at the Connection Center, the Gutstein’s primary site. Professionals that want to be trained as RDI consultants spend 4 three day trainings and six months of supervised practice as well as re-certifications at a cost of over $9000, not including living expenses and transportation. With that cost, they usually charge high prices for their services.

Research Research has not been done to show the effects of RDI. Case studies and parent testimonials are very positive, but controlled studies have not been done.

The Son-Rise Program
The Son-Rise program was developed in the 70’s by parents (Barry and Shamahria Kaufman) who were trying to reach their son who had autism. The parents spent hours in a bathroom trying to be part of the child’s world by imitating him and giving him love and acceptance. Philosophy: The Son-Rise program emphasizes hope and believing in a potential of the child. The techniques focus on socialization and rapport. Following the child’s lead, instead of tasks imposed by a teacher increases motivation. Eye contact and a longer attention span are aims of the program (Autism Treatment Center, 1998). A Look at the Program at Work: The program is centered on the parent-child relationship. The child is placed into a small playroom where most of the toys are on high shelves. The room is painted with a plain color and everything is designed to be nondistracting. The parent watches the child and imitates what the child is doing – even if the child is "stimming" (making strange movements or sounds over and over again.) The parent attempts to get into the child’s world even if the child is doing something that the parent does not want him to do. Eventually the parent slightly changes the motion or sound to see if the child will change also. The parent also attempts to get eye contact with the child as well as engagement with the activity. The parent then attempts to get turn taking with motions or sounds. Included with the turn taking is an emphasis on joint regard where the child or adult orients to where the other is pointing. The parent also may try to have the child control the interaction, such as having the child motion for the adults to get up after they have fallen on the floor after doing Ring-a-Round-the Rosy. Any attempt at communication is accepted and encouraged. Eventually imitative play

becomes part of the interactions. Pros: The activities described above usually bring the child emotionally closer to the mother or father. Motivation for play with a person, rather than just objects, may enlarge the child’s world. Social relationship skills taught with RDI are not surface social gestures like introductions, but the deeper skills needed to make friendships and socially interact comfortably. Cons: Some people object to the Son-Rise program’s playroom because the door of the playroom is locked. Others do not like the therapist parents joining in the child’s repetitive behaviors. Time and Cost The greatest area of concern seems to be the intense amount of time that the family invests in doing the Son-Rise Program. This program requires more than the 40 hours a week that the ABA program usually takes. The initial cost is $2200 for a 5-day course, not including transportation, food or lodging, in Massachusetts or in London, England. Later two more programs of Maximum Impact and Advanced Training also cost $2200 each, making the training cost $7200 total. This does not include DVDs and videos and other products that are offered. Some professionals speak of the program as cult-like because of the attachment of the families to the program. However, the parent testimonials are very supportive. Research Research with control groups and objective measurement has not been done with the Son-Rise Program. A paper describing research that has been done on autism treatments and characteristics which the program Son-Rise addresses has been presented (Melissa Hincha-Ownby, 2008), but little evidence of the effects of the program have been shown – other than parent testimonials. Greenspan, S. I. & Wieder, S., 2006. Engaging Autism: Helping Children Relate,

Communicate and Think with the DIR Floortime Approach. Perseus Publishing. Gutstein, S. E. 2001. Autism Aspergers: Solving the Relationship Puzzle. Future Horizons.

Gutstein, S. & Sheely, R.K. 2002. Relationship Development Intervention with Young Children. Jessica Kingley Publishers.

Hincha-Ownby, M. 2008; Autism educational models. Suite101.com. Koegel R.L. & Koegel, L.K.,1995. Teaching Children with Autism. Paul S. Brookes Koegel, L. & Zwbnik, C. 2005. Overcoming Autism: Finding he Answer, Strategies, and Hope that Can Transform a Child’s Life. Penguin Group. Lovaas, O.I., Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55.3-8. Maurice, C., Green, G. & Luce, S. C. 1996. Children with Autism. Pro-Ed. www.autismspeaks.org www.lovaas.com/research.php www.rdiconnect.com Behavioral Intervention for Young

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