ASD and nonmedical Interventions presented in January, 2017 BKK, Thailand

1. ASD
and
Nonmedical interventions
Topic : January 2017

2. Case
A Thai boy 11 yo. Known-case: ASD, AR
Diagnosed when he was 2 yo.; with mutism,
poor eye contact, walking with tiptoe.
He came for treatment at the hospital 7 years ago for speech therapy,
while also being cared by 3 other hospitals.
He was sent to the C & A psychiatric unit for further evaluation
2 years ago. (9 yo.)

3. Question
If you were a child psychiatrist, what kind of interventions for
clinical standard treatment in first visit ?
A. Behavioral
B. Educational
C. Communication
D. All of above

4. After you assessed all his past history of treatment, you found out he has
been being treated with speech therapist, occupational therapist and
pediatrician(medications for his behavior). Also he studies in grade 5 of
special education program at the boarding school.
What else could you do ?
His mother said she couldn’t wait for OT service queues at another
hospital, she worried about his lack of socialization. He can’t tell what he
want to others and he cries every time he was sent to the school.

5. What is the level of Evidence for effectiveness of Social skill training ?
A. High
B. Moderate
C. Low
D. Insufficient

6. Outline
• Introduction
• Concepts and Goals
• Relative factors
• Treatment modalities and Interventions
(Evidence-based)
• Resources and Application

7. Timeline of ASD Management
1995
1943
1944
1910
1900
1985
1972
1971
1964
2000 - Present
1967
1996
1987
1979
Introduction
Eclectic treatment
approach
More Evidence-based
treatments
Research on
intervention
techniques has been
established…

8. Core symptoms Introduction

9. Early Brain Plasticity
“Rewiring”
Introduction

10. A developmental model of
risk factors, risk processes,
and outcome in autism
(G dawson, 2008)
Introduction

11. Concepts
• As a lifelong disorder
• No curative treatment
• Symptomatic approaches
• Two developmental periods are
especially important :
• early preschool
• early adolescence
• Individual-based;
but combination is more effective
in most cases
Concepts & Goals
Developmental
Behavioral
Educational
Communication

12. Goals
Primary goals;
• Maximize functioning
• More independent
• Improve the quality of life
Specific goals;
• Improve social functioning and
play skills
• Improve communication skills
• Improve adaptive skills
• Decrease negative behaviors
• Promote academic functioning
and cognition
Concepts & Goals

13. Relative factors
• Age/Developmental Level
• Type & Severity of the Communication Disorder
• Strengths and Interests
• Medical Problems
• Family’s Interests and Ability to Participate
• Language Uses
• Community Resources
Relative factors
Choice of setting depends on…

14. Treatment modalities
• Developmental, Behavioral, Educational and
Communication Interventions
• Complementary and Alternative therapies: CAM
• Psychopharmacological Interventions
Treatment modalities

15. Developmental, Behavioral, Educational and
Communication Interventions (Lancet, 2014)
• Comprehensive approaches
• ABA-based
• Structured-teaching
• Targeted skill-based intervention
• Targeted behavioral intervention for
anxiety and aggression
• Parent-mediated early intervention
- EIBI
- EIBI + ESDM, DIR/floortime
⁃ TEACCH
- PECS
- Social skill training
- CBT, ABA
- Special Education
- Speech therapy
- OT, Sensory Integration thrapy
- PT
Treatment modalities

16. Interventions Target Evidence (GRADE) Framework and Goals
Comprehensive: ABA-based
• EIBI
• EIBI + Developmental and
relationship-based
approaches
<5 years
<5 years
Low or moderate
Moderate or insufficient for
ESDM; not established for
floortime
Discrete trial training, 1:1, intensive
ESDM; accelerate development in all
domains, ABA + pivotal response training
Floortime; functional emotional
development, sensory modulation, etc.
Comprehensive: structured
teaching
• TEACCH
Children, adolescents, and
adults Low
Provides structures of the environment
and activities
Targeted skill-based intervention
• PECS
• Social skill training
• Vocational intervention
Non-verbal individuals
≥6 years, adolescents, and
adults
Adolescents and adults
Moderate
Low or moderate
Insufficient
spontaneous social-communication skills
Fairly short-term to build social skills
interview training and on-the-job support
Targeted behavioral intervention
for anxiety and aggression
• CBT
Children, adolescents, and
adults Not established
Reduce anxiety: practical adaptive skills
with concrete instructions
Reduce aggression: functional behavior
assessment
Parent-mediated early
intervention
• Training for joint attention,
parent–child interaction, and
communication
Young children Insufficient or low increasing parental efficacy in real-life
settings
Evidence (GRADE)

17. EIBI
Developmental & Behavioral Ix.
Target : Young children (<5 years)
Evidence : Low or moderate
Goals : improve core symptoms of ASD and maladaptive behaviors
Effective characteristics :
• highly individualized
• up to 40 hours per week
• one-to-one direct teaching
• initially using discrete trials
• Various settings; home,
classroom, community

18. EIBI
Developmental & Behavioral Ix.
Resource : คลินิกส่งเสริมพัฒนาการเด็ก, รพ. รามาธิบดี
เครือข่าย-หน่วยงานของกรมสุขภาพจิต เช่น สถาบันราชานุกูล สถาบันยุวประ
สาทไวโยปถัมภ์ สถาบันสุขภาพจิตเด็กและวัยรุ่นราชนครินทร์
• The most significant improvements  within the first 12 months
• Pretreatment variables associated with improved outcomes;
- presence of joint attention
- functional play skills
- higher cognitive abilities
- decreased severity of autism symptoms

19. EIBI +
Developmental and relationship-based
approaches
Developmental & Behavioral Ix.
Target : Young children (<5 years)
Evidence : Moderate; insufficient for
ESDM; not established for floortime
Goals : teaching skills that are essential to development;
social communication, emotional relationships, cognitive abilities

20. Development models

21. EIBI +
Developmental and relationship-based
approaches
Developmental & Behavioral Ix.
ESDM : Comprehensive model
= Intensive ABA + Developmental and relationship-based approaches
• parents as therapists
• RCT  significant language, cognitive, and adaptive functioning gains
in 48 toddlers over a two-year period (sustained in 2 years after)
• efficacious in young children, but not clear to be generalized to other
specific or combinations of models

22. Interventions Target Evidence (GRADE) Framework and Goals
Comprehensive: ABA-based
• EIBI
• EIBI + Developmental and
relationship-based
approaches
<5 years
<5 years
Low or moderate
Moderate or insufficient for
ESDM; not established for
floortime
Discrete trial training, 1:1, intensive
ESDM; accelerate development in all
domains, ABA + pivotal response training
Floortime; functional emotional
development, sensory modulation, etc.
Comprehensive: structured
teaching
• TEACCH
Children, adolescents, and
adults Low
Provides structures of the environment
and activities
Targeted skill-based intervention
• PECS
• Social skill training
• Vocational intervention
Non-verbal individuals
≥6 years, adolescents, and
adults
Adolescents and adults
Moderate
Low or moderate
Insufficient
spontaneous social-communication skills
Fairly short-term to build social skills
interview training and on-the-job support
Targeted behavioral intervention
for anxiety and aggression
• CBT Children, adolescents, and
adults
Not established
Reduce anxiety: practical adaptive skills
with concrete instructions
Reduce aggression: functional behavior
assessment
Parent-mediated early
intervention
• Training for joint attention,
parent–child interaction, and
communication
Young children Insufficient or low increasing parental efficacy in real-life
settings

23. TEACCH
Developmental & Behavioral Ix.
Target : Children, adolescents, and adults
Evidence : Low
Goals : Provides structures of the environment and activities that
can be understood by the individual
Effective characteristics :
• Individualized person
• Family-centered plan
• Organizing the physical environment
• Predictable sequence of activities
• Routines with flexibility
• Structured work/activity systems
• Visual schedules, Visually structured
activities

24. TEACCH
Developmental & Behavioral Ix.
• CCT - comparing TEACCH with no intervention
 improvements in fine motor skills, gross motor skills, cognitive
functioning, social adaptive functioning, and communication skills
Resource :
Special Education Services, IPD, RICD
Pros;
• Uses relative strengths in visual skills and interests to supplement
weaker skills
• Uses special interests to engage for learning
• Supports self-initiated use of meaningful communication

25. TEACCH
Developmental & Behavioral Ix.

26. Interventions Target Evidence (GRADE) Framework and Goals
Comprehensive: ABA-based
• EIBI
• EIBI + Developmental and
relationship-based
approaches
<5 years
<5 years
Low or moderate
Moderate or insufficient for
ESDM; not established for
floortime
Discrete trial training, 1:1, intensive
ESDM; accelerate development in all
domains, ABA + pivotal response training
Floortime; functional emotional
development, sensory modulation, etc.
Comprehensive: structured
teaching
• TEACCH
Children, adolescents, and
adults Low
Provides structures of the environment
and activities
Targeted skill-based intervention
• PECS
• Social skill training
• Vocational intervention
Non-verbal individuals
≥6 years, adolescents, and
adults
Adolescents and adults
Moderate
Low or moderate
Insufficient
spontaneous social-communication skills
Fairly short-term to build social skills
interview training and on-the-job support
Targeted behavioral intervention
for anxiety and aggression
• CBT Children, adolescents, and
adults
Not established
Reduce anxiety: practical adaptive skills
with concrete instructions
Reduce aggression: functional behavior
assessment
Parent-mediated early
intervention
• Training for joint attention,
parent–child interaction, and
communication
Young children Insufficient or low increasing parental efficacy in real-life
settings

27. PECS
Pros :
• helpful in improving communication initiation
• decreasing frustration related to communication deficits
• more flexible incorporating photographs, pictures, scene arrays, and video
and voice output are available through personal computers and mobile
devices
Developmental & Behavioral Ix.
Target : Non-verbal individuals
Evidence : Moderate
Goals : Teaches spontaneous social-communication skills through use
of symbols or pictures

28. PECS
Developmental & Behavioral Ix.
Resource : RICD

29. Interventions Target Evidence (GRADE) Framework and Goals
Comprehensive: ABA-based
• EIBI
• EIBI + Developmental and
relationship-based
approaches
<5 years
<5 years
Low or moderate
Moderate or insufficient for
ESDM; not established for
floortime
Discrete trial training, 1:1, intensive
ESDM; accelerate development in all
domains, ABA + pivotal response training
Floortime; functional emotional
development, sensory modulation, etc.
Comprehensive: structured
teaching
• TEACCH
Children, adolescents, and
adults Low
Provides structures of the environment
and activities
Targeted skill-based intervention
• PECS
• Social skill training
• Vocational intervention
Non-verbal individuals
≥6 years, adolescents, and
adults
Adolescents and adults
Moderate
Low or moderate
Insufficient
spontaneous social-communication skills
Fairly short-term to build social skills
interview training and on-the-job support
Targeted behavioral intervention
for anxiety and aggression
• CBT Children, adolescents, and
adults
Not established
Reduce anxiety: practical adaptive skills
with concrete instructions
Reduce aggression: functional behavior
assessment
Parent-mediated early
intervention
• Training for joint attention,
parent–child interaction, and
communication
Young children Insufficient or low increasing parental efficacy in real-life
settings

30. Social skills training
Developmental & Behavioral Ix.
Target : Children aged ≥6 years, adolescents, and adults
Evidence : Low or moderate
Goals : training sessions to build social skills, usually through a group
format
Type of therapies :
• Joint attention interventions
• Modeling
• Peer training package
• Story-based intervention package/the Socials Stories

31. Effective characteristics :
• peer training > isolated social skills instruction (more effective)
• targeting social behavior (imitation, joint attention, and affect
sharing)  improving the frequency of socially engaged imitation in
toddlers
Comorbid :
Emotional or behavioral problems may influence outcomes
(not in ADHD)
Social skills training
Developmental & Behavioral Ix.

32. Interventions Target Evidence (GRADE) Framework and Goals
Comprehensive: ABA-based
• EIBI
• EIBI + Developmental and
relationship-based
approaches
<5 years
<5 years
Low or moderate
Moderate or insufficient for
ESDM; not established for
floortime
Discrete trial training, 1:1, intensive
ESDM; accelerate development in all
domains, ABA + pivotal response training
Floortime; functional emotional
development, sensory modulation, etc.
Comprehensive: structured
teaching
• TEACCH
Children, adolescents, and
adults Low
Provides structures of the environment
and activities
Targeted skill-based intervention
• PECS
• Social skill training
• Vocational intervention
Non-verbal individuals
≥6 years, adolescents, and
adults
Adolescents and adults
Moderate
Low or moderate
Insufficient
spontaneous social-communication skills
Fairly short-term to build social skills
interview training and on-the-job support
Targeted behavioral intervention
for anxiety and aggression
• CBT, ABA Children, adolescents, and
adults
Not established
Reduce anxiety: practical adaptive skills
with concrete instructions
Reduce aggression: functional behavior
assessment
Parent-mediated early
intervention
• Training for joint attention,
parent–child interaction, and
communication
Young children Insufficient or low increasing parental efficacy in real-life
settings

33. CBT
Developmental & Behavioral Ix.
Target : Children, adolescents, and adults
Evidence : Not established
Goals : reduce anxiety
Concepts :
• modifies dysfunctional
• teaching of practical adaptive skills with concrete instructions
• often combined with social skill training
• systematic desensitisation is useful particularly for individuals with ID

34. ABA
Developmental & Behavioral Ix.
Target : Children, adolescents, and adults
Evidence : Not established
Goals : reduce aggression
Concepts :
• apply functional behavior assessment
• teach alternative behaviors and skills; • antecedent manipulations
• changes in instructional context
• reinforcement-based strategies
• behavior reduction strategies

35. Special Education
Effective characteristics :
• intensive, individualized, staff-to-student = 1: 1-2
• experienced, interdisciplinary team of providers
• family involvement
Educational Ix.
Target : Young children (<5 years)
Evidence : Low or moderate
Goals : enhancing verbal and nonverbal communication, academic
skills, social, motor, and behavioral capabilities

36. Special Education
• Min. of 25 hrs/wk
• Functional analysis of behavior problems
• Ongoing program evaluation and adjustment
• Close monitoring and modification as the child's needs change
• Curriculum emphasizing attention, imitation, communication, play,
and social interaction
• Highly supportive teaching environment
• Predictability and structure
Educational Ix.

37. Special Education
Educational Ix.
What to evaluate ?
• chronologic age
• developmental level
• specific strengths and
weaknesses
• family needs
Resource :
Special Education Services

38. Communication Ix.
Speech therapy (Traditional)
Target : Any,
Evidence : -
Goals :
• improve core deficits in social and functional
communication skills
• promote communication skills to improve in
overall functioning
• specific goals may vary depending upon the level of function

39. Communication Ix.
Speech therapy
For individuals who do not yet use words; use of alternative
communication modalities
e.g. sign language, communication boards, visual supports, picture exchange,
and other forms of augmentative communication
 For individuals with fluent speech, the focus should be on
pragmatic language skills training

40. PRACTICE PARAMETERS (2014)
Methods Available for the Delivery of Social Reciprocity/
Pragmatic Language-Oriented Interventions
Developmental Level Methods
Infant/preschool (play based) guided participation, Do-Watch-Listen-Say,
play organizers, buddy skills
School age social stories, social skills groups peer network/circle of friends
Adolescence peer network/circle of friends
visual schedule/verbal rehearsal
social skills group, social thinking
training scripts
[CS]
Speech therapy
Speech therapy + Social skills training
Communication Ix.

41. Speech therapy
Communication Ix.

42. Communication Ix.
Speech therapy
หน่วยแก้ไขการพูด
รพ. รามาธิบดีและโรงเรียนแพทย์ทุกแห่ง
สถาบันราชานุกูล, สถาบันสุขภาพเด็กแห่งชาติฯ
สถาบันประสาทวิทยา, สถาบันสุขภาพจิตเด็ก
และวัยรุ่นราชนครินทร์, โรงพยาบาลเจริญกรุง
ประชารักษ์, โรงพยาบาลสมเด็จพระปิ่นเกล้า
ฯลฯ
Resource :

43. Sensory Integration therapy, Traditional OT
Target : Young children to adolescent
Evidence : -/inconsistent
Goals :
• young children  focuses on enhancing sensory processing,
sensorimotor and social-behavioral performance, self-care and
participation in play
• older children  may include social and behavioral performance
and transition to work and independence in the community
Developmental-based Ix.

44. Traditional OT
Developmental-based Ix.
Concepts:
• associated ASD features : motor delays  atypical features
• Motor delays effect ability to mimic another’s actions as well as to
participate in goal-directed behavior,
• provide means for learning other skills (social and academics)

45. Sensory Integration therapy (SIT)
Concepts:
• clinical-based
• child- directed
• uses play activities to engage
child participation and
challenge sensory processing
and motor planning skills
• daily routine (home, school)
Areas of Possible Sensory Intervention
Developmental-based Ix.

46. Sensory Integration therapy, OT
Resource :
หน่วยงานกิจกรรมบาบัดของสถาบัน
ในสังกัดกรมสุขภาพจิต เช่น สถาบัน
ราชานุกูล, สถาบันสุขภาพจิตเด็ก
และวัยรุ่นราชนครินทร์, ยุวประสาท
ไวโยปถัมภ์
Developmental-based Ix.

47. Physical therapy (PT)
Target : Any ages
Evidence : -/inconsistent
Goals:
• Improve participation in activities of daily living
• Acquire new motor skills, motor strength
• Develop better coordination
• Improve reciprocal play skills (throw & catch a ball)
• Develop motor imitation skills
Developmental-based Ix.

48. Physical therapy (PT) : Vojta therapy
Developmental-based Ix.
Reflex Locomotion
• Reflex Creeping
• Reflex Rolling

49. Complementary and Alternative therapies
• Hippo therapy/ Therapeutic
horseback riding
• Art therapy
• Music therapy
• Drama therapy
• Auditory Integration Therapy (AIT)
• HEG, Neurofeedback
• Hyperbaric oxygen therapy (HBOT)
• Hydrotherapy
• Acupuncture
• Nutritional supplements and diets
(e.g. Omega-3 fatty acids, Casein-
and Gluten-free, Vit. B6, 12, Mg,
Melatonin, etc.)
And many more…
Treatment modalities : CAM

50. Complementary and Alternative therapies
Treatment modalities : CAM

51. Complementary and Alternative therapies
Treatment modalities : CAM

52. Complementary and Alternative therapies
Treatment modalities : CAM
Nutritional supplements and diets;
• Possible benefit, potential risk
- Gluten-free,
casein-free diet (2C)
• Unknown benefit, potential risk
- Vitamin B6 and magnesium
• Possible benefit, low risk
- Melatonin
- Oxytocin
- Sulforaphane
• Unknown benefit, low risk
- Omega-3 fatty acids
- Probiotics

53. Clinical Application
• Ramathibodi hospital
• Child Development Unit : Early Intervention Clinic อาคารสิริกิติ์ ชั้น 3
• Speech and Language Clinic/ ภาควิชาวิทยาศาสตร์สื่อความหมายและความผิดปกติของการสื่อ
ความหมาย : Speech therapy อาคาร 4 ชั้น 4
• Others services;
- Speech : หน่วยแก้ไขการพูด โรงเรียนแพทย์ทุกแห่ง, สถาบันราชานุกูล, สถาบันสุขภาพเด็กแห่งชาติฯ
สถาบันประสาทวิทยา, สถาบันสุขภาพจิตเด็กและวัยรุ่นราชนครินทร์, โรงพยาบาลเจริญกรุงประชารักษ์, โรงพยาบาล
สมเด็จพระปิ่นเกล้า ฯลฯ
- OT,PT : หน่วยงานกิจกรรมบาบัดและกายภาพบาบัดของสถาบันในสังกัดกรมสุขภาพจิต เช่น สถาบันราชานุกูล,
สถาบันสุขภาพจิตเด็กและวัยรุ่นราชนครินทร์, ยุวประสาทไวโยปถัมภ์ เป็นต้น
Resources and Application

54. National Resources (For Parents)
• สถาบันสุขภาพจิตเด็กและวัยรุ่นราชนครินทร์ : http://www.smartteen.net/main
• สถาบันราชานุกูล : http://www.rajanukul.go.th
• โรงพยาบาลยุวประสาทไวทโยปถัมภ์ : http://ycap.go.th
• สถาบันสุขภาพจิตเด็กและวัยรุ่นภาคตะวันออกเฉียงเหนือ : http://www.necam.go.th
• Center for Autism Recovery and Education - CARE Thailand :
www.carethaiautism.com
• http://rajanukul.go.th/main/ebook.php (free social stories)
Resources and Application

55. International Resources(For Parents)
Autism Today: largest autism-related information online; multilingual
Action for Autism: worldwide links to autism organization, resources in about 100 different countries
www.autism-india.org/worldorgs.com
Center for the Study of Autism
www.autism.org
Autistic Living: site developed by parents for parents
www.autisticliving.com
Autism Speaks: world's largest autism advocacy organization
http://www.autismspeaks.org/
Autism Resources: over 16 languages
www.autism-resources/links/nonenglish.html
Autism Society of America (ASA)
www.autism-society.org
Autism Research Institute
www.autism.com/
Resources and Application

56. What is the level of Evidence for effectiveness of Social skill training ?
A. High
B. Moderate
C. Low
D. Insufficient
Case (continue)
Continue Sensory integration therapy with Occupational therapist and
Speech therapy sessions…..

57. References
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children with autism spectrum disorders (ASD). Cochrane Database Syst Rev 2012; 10:CD009260
• Howlin P, Magiati I, Charman T. Systematic review of early intensive behavioral interventions for
children with autism. Am J Intellect Dev Disabil 2009; 114:23.
• Dawson G, Rogers S, Munson J, et al. Randomized, controlled trial of an intervention for toddlers
with autism: the Early Start Denver Model. Pediatrics 2010; 125:e17.
• Autism(Seminar). Lancet 2014; 383: 896–910. Published Online September 26, 2013
• Practice Parameter for the Assessment and Treatment of Children and Adolescents With Autism
Spectrum Disorder. JAACAP, Feb. 2014
• Reichow B, Steiner AM, Volkmar F. Social skills groups for people aged 6 to 21 with autism
spectrum disorders (ASD). Cochrane Database Syst Rev 2012; :CD008511.
• A National clinical guideline- SIGN145 : assessment, diagnosis and interventions for ASD. June
2016 (Healthcare Improvement Scotland)
• Management of autism in children and young people: summary of NICE and SCIE guidance. BMJ
2013;347:f4865 doi: 10.1136/bmj.f4865 (Published 28 August 2013)
• LeBlanc & Gillis. Behavioral Interventions for Children with Autism Spectrum Disorders. Pediatr
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