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Treatments for Autism Spectrum Disorders AUTISM SPECTRUM Navigating the Maze Lynda Maniscalco M.S. CCC-SLP
Introduction The diagnosis of an Autism Spectrum Disorder presents parents and clinicians with a veritable maze of programs and therapies. What is out there? Which programs are best for my child/student? What are the pros and cons?
What will the role of the clinician (OT, PT, SLP) be in implementing this program or therapy? For the next few minutes we will look at an overview of the most standard and popular treatment programs and therapies for individuals on the Autism Spectrum.
Treatments for Core Symptoms Treatments for Autism Spectrum Disorders can be divided into two categories: Treatments for Core Symptoms which address behavioral, developmental and educational needs specific to autism. Other therapies such as Occupational, Physical, or Speech Therapy that while essential to the treatment of Autism is not exclusive of other disorders such as developmental delays or cerebral palsy.
Applied Behavioral Analysis This treatment program (ABA) is based on the principles of positive reinforcement of B.F. Skinner. Simply, it is the repetitive use of positive reinforcement to teach specific skills and decrease inappropriate behaviors. What is occurring in the child’s environment to cause negative behaviors?
ABA Three Step Procedure Antecedent: The verbal or physical stimulus such as a command or request. Resulting Behavioral response to stimulus or a lack of response Consequence: the positive reinforcement or no response for inappropriate behavior
ABA Intervention ABA is not synonymous with Discrete Trial Training. DTT was developed by Dr. O. IvarLovass. DTT is a strategy used in ABA In ABA, skills are broken down into small, discrete tasks which are taught using prompts, which are faded out gradually as a skill is mastered. Students are positively reinforced with either verbal praise or something tangible that he/she finds rewarding.
ABA programs are carried out at school or in the home with a one on one aide The goal is the carryover of the skills to other environments. Facilitated play with peers is also part of this program. The ABA provider is responsible for data collection and analysis.
Providers must be board certified behavior analysts. The provider is responsible for writing and managing the program. Individual “Trainers”, who are not necessarily board certified provide the daily intervention. Sessions last between 2-3 hours with 10-15 minute breaks at the end of each hour for incidental teaching and play time. Intervention requires 35-40 hours per week with families encouraged to use these techniques daily.
While punishments are not generally used, a therapist may intervene if a child is hurting himself by non-injurious methods such as a light spray of water in the face.
Pros: ABA is reputed by many to be the most successful therapy available. “ We found that 48% of all children showed rapid learning and achieved average post-treatment scores, and at age 7 were succeeding in regular classrooms.”(Lovaas, 1987; McEachin, Smith and Lovaas, 1993) The data collected on a daily basis allows parents and team members to closely follow the students progress.
40 hours of intervention a week is often considered to be just too much for many families. The cost is prohibitive. While some schools will provide ABA, few will pay the cost of 40 hours per week of one on one intervention for “just” one child. Critics suggest that ABA can create an “emotionless, robotic” child who has difficulty carrying over skills to a natural environment. Cons:
The Therapist’s Role in ABA ABA is usually paired with speech therapy in early intervention. The SLP must be aware of the specific plan for each child and regularly communicate the the ABA therapist. Speech Therapy, Occupational Therapy, and Physical Therapy are often areas where the child can generalize and practice skills learned in ABA Therapy. Each discipline brings to the ABA program differing goals and objectives in terms of communication modalities, positioning and sensory needs. www.slp-aba.net
Pivotal Response Treatment This program was developed at the University of California at Santa Barbara by Dr. Robert Koegel, Dr. Lynn Kern Koegel, and Dr. Laura Shrubman. It is also referred to as the Natural Language Paradigm and is based on ABA principles.
The goal of this intervention is to teach language, decrease inappropriate behaviors, and increase social skills and academics. The focus on intervention is on those skills pivotal to the normal development of many other skills and behaviors. Pivotal skills include: communication skills, play, social skills, and the ability to monitor one’s own behavior. Pivotal Response Treatment
PRT differs from ABA in that it is child directed PRT is provided by psychologists, SPED teachers, Speech Pathologists, and other providers specifically trained in PRT. PRT Certification is offered through the Koegel Autism Center: www.education.UCSB.edu/autism
PRT programs require at least 25 hours of intervention weekly. All family members are encouraged to use PVT methods consistently with the student. Some disadvantages include: financing, finding local providers and trying to live a “normal” family life while constantly in “therapy mode”.
The Therapist’s Role in PRT As in ABA, the SLP, OT, and PT work with the PRT provider in developing a treatment program. The PRT provider should provide suggestions to other professionals on targeting pivotal behaviors. Communication between therapists and families is a must. All providers should focus on using the same prompting strategies. PRT blends especially well with Speech Therapy as it can be adapted to teach a variety of skills including symbolic and sociodramatic play and joint attention.
Verbal Behavior This program uses Skinner’s analysis of language as a system to teach language and modify behaviors. It encourages the student to learn language by developing a connection between a word and its meaning. Verbal Behavior is based on the idea that the way we talk influences how sensitive or aware we are of changes to our environment.
The intervention first focuses on using language to request or “mands”. Then the focus turns to naming or labeling referred to in the program as “Tact” Finally the focus of treatment moves to “Intra-Verbal Communication” which includes understanding and use of wh-questions and conversation.
Floor Time This approach is based on the Developmental Individual Difference Model from Dr. Stanley Greenspan. Floor Time is simply the idea that a child’s communication skills can be improved by building on his/her strengths while playing together on the floor.
Floor Time: The overall goal Six developmental milestones Self regulation and interest in the world Intimacy or a special love for others Two way communication Complex communication Emotional ideas Emotional thinking
Implementation The therapist enters the child’s activities and follows the child’s leads in play and guides the child in expanding his/her interactions. Parents are instructed on how to move the child to more complicated interactions which are referred to as “Opening and Closing Communication Circles. Speech, motor, and cognitive skills are addressed “Through a synthesized emphases on emotional development.
Floor Time is sometimes used in conjuction with ABA. Intervention is delivered in a low stimulus environment from 2-5 hours per day with the child’s family using the principles in daily life. www.floortime.org www.stanleygreenspan.com Interdisciplinary Council on Developmental Learning Disorders www.icdl.com www.play-to-learn.com/dir_floortime.htm Greespan, S., & Weider, S. (1998). “The Child with Special Needs”. Reading, MA: Addison-Wesley.
Floortime: Playtime for the Clinician The principles of Floortime can easily be included in the therapy techniques of Speech, OT and PT. Floortime allows for a fun, naturally reinforcing therapy environment. SLP’s, OT’s, and PT’s already employ a variety of play therapy techniques in their interventions.
Relationship Development Intervention Developed by Dr. Steven Gutstien It is a parent based program using the following “Dynamic Intelligence Objectives”
Dynamic Intelligence Objectives Emotional Referencing: the use of emotional feedback to learn from the experiences of others Social Coordination: the ability to observe and continually regulate ones behavior in order to participate in spontaneous relationships involving collaboration and exchange of emotion.
Dynamic Intelligence Objectives Declarative Language: using language and non-verbal communication to express curiosity and inviting others to interact and share perceptions and feelings and to corridinate one’s action with others. Flexible Thinking: ability to adapt rapidly and change strategies and alter plans based on changing circumstances.
Dynamic Intelligence Objectives Relational Information Processing: the ability to obtain meaning based on a larger context and solving problems that have no clear right or wrong answers. Foresight and Hindsight: the ability to reflect on past experiences and anticipate potential future scenarios.
Intervention In this program, the child begins working one on one with the parent. Then another peer is added who is at a similar level of relationship development. As the child progresses, other children are added to the group and the environments are changed. The curriculum consists of six levels: Novice, Apprentice, Challenger, Explorer, and Partner. The program guides the child to develop friendships, and show empathy.
Parents learn the program through training seminars from an RDI certified consultant www.rdiconnect.com Intervention
Pros and Cons RDI is not considered a complete treatment program. It is a program designed specifically for parent implementation.
RDI: A Therapists Perspective Since RDI is meant for implementation by the parent only, it would be important for the SLP, OT, and PT to be aware of the principles of RDI and the progress of the student in this intervention. Communication with parents and floor time intervention specialist is vital to the development of a multi-disciplinary team approach.
TEACCH Training and Education of Autistic and Related CommuniCation for Handicapped Children (TEACCH) Developed by Eric Schopler, PhD of the University of North Carolina This is a highly structured program based on the “Culture of Autism”.
Culture of Autism This term refers to the “relative strengths and difficulties shared by people with autism and that are relevant to how they learn”. (www.autismspeaks.com)
Intervention In this approach, children are evaluated to determine emergent skills and intervention is designed to build on these skills. The intervention plan is developed for each individual child to help plan activities and experiences. The child refers to visual supports such as picture schedules to help them predict and cope with daily activities.
The TEACCH program is for home or school interventions. Training is available through TEACCH Centers in North Carolina and by TEACCH trained pshychologists, SPED Teachers and SLPS www.teacch.com
Pros and Cons This program focuses on cultivation of the child’s strengths and interests rather than focusing on his/her deficits alone. The strengths of those with autism (visual skills, recognizing details, and memory can become the basis of successful adult functioning (Ohio’s Parent Guide to Autism Spectrum Disorders – Mesibov and Shea, 2006).
TEACCH and the Therapist SLPs, OTs, and PT’s can easily include TEACCH procedures in their therapy sessions. Therapists can incorporate the use of schedules, social stories and other techniques in their therapy plans, encouraging skill generalization.
SCERTS Social Communication, Emotional Regulation, and Transactional Support Developed by Barry Prizant, PhD., Amy Wetherby, PhD, Emily Rubin and Amy Laurent SCERTS draws from other programs such as ABA, Pivotal Response Treatment, TEACCH, Floor Time and RDI.
The main difference between SCERTS and ABA is that SCERTS encourages child initiated communication in daily life. SCERTS aim is to help the child achieve “Authentic Progress”, which is defined as the ability to learn and spontaneously carry over functional skills into various settings and with many communication partners. SCERTS
The Focal Aspects of SCERTS Social Communication: spontaneous functional communication, emotional expression and secure and trusting relationships with others Emotional Regulation: the ability to maintain a well-regulated emotional state and the ability to cope with daily stresses.
Transactional Support: development and implementation of supports to assist communication partners to adapt the environment and provide the tools to enhance learning(picture communication, written schedules, sensory supports). Specific plans are developed to provide education and emotional support for families and to encourage teamwork among the intervention team.
Intervention This program provides for children with Autism to learn with and from other children who are good social and language models Transitional supports (environmental accommodations) and learning supports (picture schedules or visual organizers)
This program is usually provided in the school settings by SCERTS trained professionals www.scerts.com www.barryprizant.com
Pros and Cons Unlike ABA, this program focuses on group intervention rather than one on one treatment. Uses a multidisiciplinary team approach SCERTS is not an exclusive program and accepts other educational models that the team deems appropriate.
Therapist’s Perspective The SCERTS model is an interdisciplinary approach. The model uses the knowledge base and experience of general and special educators, SLPs, OTs, PTs, and other professionals. Therapists should be familiar with SCERTS principles and techniques and communication with the SCERTS provider, parents other members of the intervention team is critical to the success of the program.
The Hanen Approach This approach is based on the belief that parents should be the child’s language teachers, because they have the strongest bond and have many opportunities to teach language in the natural contexts of daily living. Parents are trained by Hanen certified SLPS.
The Hanen Approach Trained parents can then adapt the approach to meet the individual and unique needs of their child. Programs for Parents include: “It Takes Two To Talk”-Hanen program for parents. “More Than Words”- Hanen program for parents of children with Autism Spectrum Disorders “Target Word” – Hanen program for parents of Late Talkers.
The Hanen Centre has also developed supports for teachers (Learning Language and Loving It – A Guide to Promoting Children’s Social, Language, and Literacy Development second edition – Weitzman and Greenber, 2002). www.hanen.org The Hanen Approach
Pros and Cons Parents are to be the sole providers for this approach. It is not intended to be a curriculum It does not exclude of other educational models.
Integrated Play Groups Developed by Pamela J. Wolfberg, PhD. Promotes socialization and imagination in children with ASD or Developmental Delays through play with non-disabled peers. Integrated Play Groups follow rules for creation of an appropriate play environment and selection of materials, preparation of peers for play, measurement of progress and guided play.
Integrated Play Groups Focus is on social communication in the areas of imitation, joint attention, and imaginative and creative play. Ohio’s Parent Guide to Autism Spectrum Disorders Wolfberg, P.J. (2003). “Peer Play and the Autism Spectrum: The art of guiding children’s socialization and imagination. Shawnee Mission, KS: Autism Asperger Publishing Company.
Pros and Cons This is a wonderful venue for addressing social skills and developing peer relationships. Care must be taken to follow procedures for the appropriate environment, selected materials, peer preparation, and data collection.
Play and Therapy!! As in Floortime, Integrated play groups fall in line easily with play therapy techniques across professions. The SLP would see significant benefits to the inclusion of Integrated Play Groups in addressing social skills.
The Son-Rise Program The Son-Rise Program was developed by Barry Neill Kaufman and his wife when their son Raun was diagnosed as severely and incurably autistic. The program is a system of treatment and education focusing on joining children instead of working against them.
Principles of the Son-Rise Program Joining in the child’s repetitive and ritualistic behaviors is considered the “key to unlocking the mystery of these behaviors”, facilitating eye-contact, social behaviors and the inclusion of others in play. Utilizing a child’s own motivations advances learning and builds the foundation for education and skill acquisition. Teaching through interactive play results in effective and meaningful socialization and communication.
The program encourages providers and parents to teach with enthusiasm and to employ a non-judgemental attitude. This approach considers the parent to be the most important and best resource. It encourages the creation of a distraction free work and play environment to facilitate optimal learning. Principles of the Son-Rise Program
Intervention Intervention is provided through parent-training at one the Autism Treatment Centers of America. Parents are the primary providers, however they can include family and friends in the intervention process. The Son-Rise Program combines effectively with other complementary therapies (ie. Biomedical interventions, sensory integration, diet and Auditory Integration therapies).
Pros and Cons The cost in terms of finances and time required for daily intervention may be prohibitive for many parents. The Son-Rise Program has come under fire for “promoting” a cure for autism. It is interesting to note that this program is not even listed in the Ohio Parent’s Guide to Autism Spectrum Disorders or on the Autism Speaks Website. www.autismtreatmentcenterofamerica.com
The Role of other therapies in the Son-Rise program
Resources Autism Speaks www.autismspeaks.com Ohio Center for Autism and Low Incidence www.ocali.org SLP-ABA Journal www.slp-aba.net www.about.com Koegel Autism Center www.education.UCSB.edu/autism www.floortime.org www.stanleygreenspan.com
Interdisciplinary Council on Developmental Learning Disorders www.icdl.com www.play-to-learn.com/dirfloortime.htm Greenspan,S.,& Weider, S. (1998). “The Child with Special Needs.” Reading, MA: Addison-Wesley Relationship Development Intervention www.rdi.com TEACCHwww.teacch.com SCERTSwww.scerts.com The Hanen Approach www.hanen.org www.autismtreatmentcenterofamerica.com “American Maze”, Dale Wilkins. Used by permission 2/10 Resources and Credits
In Summary There are many, many different approaches to treating Autism Spectrum Disorders. This list is by no means comprehensive. Parents and therapists should engage in careful research before committing to any specific program.