Autism behavioral therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The main goals of treatment are to lessen associated deficits and family distress, and to increase quality of life and functional independence. No single treatment is best and treatment is typically tailored to the child's needs. Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills,[1] and often improve functioning and decrease symptom severity and maladaptive behaviors;[2] claims that intervention by age two to three years is crucial[3] are not substantiated.
Behavioral Therapy
- Available approaches include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy.[1]
- Educational interventions have some effectiveness in children: intensive ABA treatment has demonstrated effectiveness in enhancing global functioning in preschool children[4] and is well-established for improving intellectual performance of young children.[2]
- The limited research on the effectiveness of adult residential programs shows mixed results.[5]
Educational Interventions
Educational interventions attempt to help children not only to learn academic subjects and gain traditional readiness skills, but also to communicate functionally and spontaneously, socialize with skills such as joint attention, gain cognitive skills such as symbolic play, reduce disruptive behavior, and generalize by applying learned skills to new situations. Several model programs have been developed, which in practice often overlap and share many features, including:[1]
- Early intervention that does not wait for a definitive diagnosis;
- Intense intervention, at least 25 hours/week, 12 months/year;
- Low student/teacher ratio;
- Family involvement, including training of parents;
- Interaction with neurotypical peers;
- Structure that includes predictable routine and clear physical boundaries to lessen distraction; and
- Ongoing measurement of a systematically planned intervention, resulting in adjustments as needed.
Several educational intervention methods are available, as discussed below. They can take place at home, at school, or at a center devoted to autism treatment. A 2007 study found that augmenting a center-based program with weekly home visits by a special education teacher improved cognitive development and behavior.[6] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills;[1] claims that intervention by age two to three years is crucial[7] are not substantiated.[8]
Applied Behavior Analysis
Interventions based on applied behavior analysis (ABA) focus on teaching tasks one-on-one using the behaviorist principles of stimulus, response and reward,[9] and on reliable measurement and objective evaluation of observed behavior.[1] There is wide variation in the professional practice of behavior analysis and among the assessments and interventions used in school-based ABA programs.[10] Many interventions rely heavily on discrete trial teaching (DTT) methods, which use stimulus-response-reward techniques to teach foundational skills such as attention, compliance, and imitation. However, children have problems using DTT-taught skills in natural environments.[1] In functional behavior analysis, a common assessment technique, a teacher formulates a clear description of a problem behavior, identifies antecedents, consequents, and other environmental factors that maintain the behavior, develops hypotheses about what motivates the behavior, and collects observations to test the hypotheses.[1] A few more-comprehensive ABA programs use multiple assessment and intervention methods individually and dynamically.[10]
ABA has demonstrated effectiveness in several controlled studies: children have been shown to make sustained gains in academic performance, adaptive behavior, and language, with outcomes significantly better than control groups.[1] For example, a 2005 California study found that early intensive behavior analytic treatment, a form of ABA, was substantially more effective for preschool children with autism than the mixture of methods provided in many programs.[9] However, a 2007 British study found that home-based early intensive behavioral interventions, another ABA form, was no more effective than nursery-based eclectic programs.[11]
TEACCH
TEACCH, which has come to be called "structured teaching", emphasizes structure by using organized physical environments, predictably sequenced activities, visual schedules and visually structured activities, and structured work/activity systems where each child can practice various tasks.[1] Parents are taught to implement the treatment at home. A 1998 controlled trial found that children treated with a TEACCH-based home program improved significantly more than a control group.[12]
Floortime
Floortime was developed by Stanley Greenspan. The intervention focuses on facilitating attachment between the child with autism and the parent through the act of play. The parent follows the child's lead and joins with the child in his or her preferred activity, even if the activity would be considered peculiar.
Relationship Development Intervention
Relationship Development Intervention (RDI) is a treatment program developed by Dr. Steven E. Gutstein. Rather than teaching specific skills that are seen as lacking, RDI focuses primarily on building a general "dynamic intelligence" believed to underlie the acquisition of social skills demonstrated in neurotypical children. It also focuses on the building blocks of motivation by developing episodic memory (seen as impaired in autism) and filling it with the child's own personal stories of competence and mastery. RDI emphasizes declarative (as opposed to imperative) communication, and aims for an appropriate balance of verbal and nonverbal communication.
Dr. Gutstein claims that 70% of his patients improved their ADOS diagnostic category within 18 months and that a similar proportion are able to enter school without a shadow teacher or other personal assistant, though to date there is no peer-reviewed published research on the RDI protocol.
Communication Interventions
Communication interventions fall into two major categories. First, many autistic children do not speak, or have little speech, or have difficulties in effective use of language. Interventions that attempt to improve communication are commonly conducted by speech and language therapists, and work on joint attention, communicative intent, and alternative or augmented communication methods such as visual methods.[13] Little solid research supports the efficacy of speech therapy for autism.[14] A 2006 study reported benefits both for joint attention intervention and for symbolic play intervention,[15] and a 2007 study found that joint attention intervention is more likely than symbolic play intervention to cause children to engage later in shared interactions.[16]
Second, social skills treatment attempts to increase social and communicative skills of autistic individuals, addressing a core deficit of autism. A wide range of intervention approaches is available, including modeling and reinforcement, adult and peer mediation strategies, peer tutoring, social games and stories, self-management, pivotal response therapy, video modeling, direct instruction, visual cuing, circle of friends, and social-skills groups.[17] A 2007 meta-analysis of 55 studies of school-based social skills intervention found that they were minimally effective for children and adolescents with ASD,[18] and a 2007 review found that social skills training has minimal empirical support for children with Asperger syndrome or high-functioning autism.[19]
Sensory Integration
Unusual responses to sensory stimuli are more common and prominent in autistic children, although there is no good evidence that sensory symptoms differentiate autism from other developmental disorders.[20] Several therapies have been developed to treat Sensory Integration Dysfunction.[21] Some of these treatments (for example, sensorimotor handling) have a questionable rationale and no empirical evidence. Other treatments (for example, prism lenses, physical exercise, and auditory integration training) have had studies with small positive outcomes, but few conclusions can be made about them due to methodological problems with the studies.[22] Although replicable treatments have been described and valid outcome measures are known, gaps exist in knowledge related to sensory integration dysfunction and therapy.[23]
Therapy in Education
Children with autism are affected by their symptoms every day, which set them apart from unaffected students. Because of problems with receptive language and theory of mind, they can have difficulty understanding some classroom directions and instruction, along with subtle vocal and facial cues of teachers. This inability to fully decipher the world around them often makes education stressful. Teachers need to be aware of a student's disorder, and ideally should have specific training in autism education, so that they are able to help the student get the best out of his or her classroom experiences.
Some students learn more effectively with visual aids as they are better able to understand material presented visually. Because of this, many teachers create “visual schedules” for their autistic students. This allows students to concretely see what is going on throughout the day, so they know what to prepare for and what activity they will be doing next. Some autistic children have trouble going from one activity to the next, so this visual schedule can help to reduce stress.
Research has shown that working in pairs may be beneficial to autistic children. Autistic students have problems not only with language and communication, but with socialization as well. By facilitating peer interaction, teachers can help their students with autism make friends, which in turn can help them cope with problems or understand the world around them. This can help them to become more integrated into the mainstream environment of the classroom.
A teacher's aide can also be useful to the student. The aide is able to give more elaborate directions that the teacher may not have time to explain to the autistic child and can help the child to stay at an equivalent level to the rest of the class through the special one-on-one instruction. However, some argue that students with one-on-one aides may become overly dependent on the help, thus leading to difficulty with independence later on.
There are many different techniques that teachers can use to assist their students. A teacher needs to become familiar with the child’s disorder to know what will work best with that particular child. Every child is going to be different and teachers have to be able to adjust with every one of them.
Students with autism spectrum disorders sometimes have high levels of anxiety and stress, particularly in social environments like school. If a student exhibits aggressive or explosive behavior, it is important for educational teams to recognize the impact of stress and anxiety. Preparing students for new situations, such as through writing social stories, can lower anxiety. Teaching social and emotional concepts using systematic teaching approaches such as The Incredible 5-Point Scale or other cognitive behavioral strategies can increase a student's ability to control excessive behavioral reactions.
Animal-assisted Therapy
Animal-assisted therapy, where an animal such as a dog becomes a basic part of a person's treatment, is a controversial treatment for some symptoms. A 2007 meta-analysis found that animal-assisted therapy is associated with a moderate improvement in autism spectrum symptoms.[24] Reviews of published dolphin-assisted therapy (DAT) studies have found important methodological flaws and have concluded that there is no compelling scientific evidence that DAT is a legitimate therapy or that it affords any more than fleeting improvements in mood.[25]
Prosthetics
Affective computing devices, typically with image or voice recognition capabilities, have been proposed to help autistic individuals improve their social communication skills. These devices are still under development. Robots have also been proposed as educational aids for autistic children.[26]
Neurofeedback
Neurofeedback has been hypothesized to improve focusing and decrease anxiety in individuals with ASD. One pilot study investigated this hypothesis in 10 adolescent boys diagnosed with Asperger syndrome. Five boys dropped out during the study; results on the remaining boys were positive but were not statistically significant.[27]
Son-Rise
Son-Rise is a home-based program with emphasis on eye contact, accepting the child without judgment, and engaging the child in a noncoercive way. Proponents claim that children will decide to become non-autistic after parents accept them for who they are and engage them in play. The program was started by the parents of Raun Kaufman, who is claimed to have gone from being autistic to normal via the treatment in the early 1970s.[28] No independent study has tested the efficacy of the program, but a 2003 study found that involvement with the program led to more drawbacks than benefits for the involved families over time,[29] and a 2006 study found that the program is not always implemented as it is typically described in the literature, which suggests it will be difficult to evaluate its efficacy.[30]
Patterning
Patterning is a set of exercises that attempts to improve the organization of a child's neurologic impairments. It has been used for decades to treat children with many unrelated neurologic disorders, including autism. The therapy is based on oversimplified theories and is not supported by carefully designed research studies.[31]
Parent Mediated Interventions
Parent mediated interventions offer support and practical advice to parents of autistic children.[13] Randomized and controlled studies suggest that parent training leads to reduced maternal depression, improved maternal knowledge of autism and communication style, and improved child communicative behavior.[32] A 2006 randomized controlled trial (RCT) found that a 20-week parent education and behavior management (PEBM) program provided significant improvements in parental mental health and well-being, particularly for parents with preexisting mental health problems.[33]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Myers SM, Johnson CP, Council on Children with Disabilities (2007). "Management of children with autism spectrum disorders". Pediatrics. 120 (5): 1162–82. doi:10.1542/peds.2007-2362. PMID 17967921. Lay summary – AAP (2007-10-29).
- ↑ 2.0 2.1 Rogers SJ, Vismara LA (2008). "Evidence-based comprehensive treatments for early autism". J Clin Child Adolesc Psychol. 37 (1): 8–38. doi:10.1080/15374410701817808. PMID 18444052.
- ↑ Pettus A (2008). "A spectrum of disorders". Harv Mag. 110 (3): 27–31, 89–91.
- ↑ Eikeseth S (2008). "Outcome of comprehensive psycho-educational interventions for young children with autism". Res Dev Disabil. doi:10.1016/j.ridd.2008.02.003. PMID 18385012.
- ↑ Van Bourgondien ME, Reichle NC, Schopler E (2003). "Effects of a model treatment approach on adults with autism". J Autism Dev Disord. 33 (2): 131–40. doi:10.1023/A:1022931224934. PMID 12757352.
- ↑ Rickards AL, Walstab JE, Wright-Rossi RA, Simpson J, Reddihough DS (2007). "A randomized, controlled trial of a home-based intervention program for children with autism and developmental delay". J Dev Behav Pediatr. 28 (4): 308–16. doi:10.1097/DBP.0b013e318032792e. PMID 17700083.
- ↑ Pettus A (2008). "A spectrum of disorders". Harv Mag. 110 (3): 27–31, 89–91.
- ↑ Howlin P (2006). "Autism spectrum disorders". Psychiatry. 5 (9): 320–4. doi:10.1053/j.mppsy.2006.06.007.
- ↑ 9.0 9.1 Howard JS, Sparkman CR, Cohen HG, Green G, Stanislaw H (2005). "A comparison of intensive behavior analytic and eclectic treatments for young children with autism". Res Dev Disabil. 26 (4): 359–83. doi:10.1016/j.ridd.2004.09.005. PMID 15766629.
- ↑ 10.0 10.1 Steege MW, Mace FC, Perry L, Longenecker H (2007). "Applied behavior analysis: beyond discrete trial teaching". Psychol Schools. 44 (1): 91–9. doi:10.1002/pits.20208.
- ↑ Magiati I, Charman T, Howlin P (2007). "A two-year prospective follow-up study of community-based early intensive behavioural intervention and specialist nursery provision for children with autism spectrum disorders". J Child Psychol Psychiatry. 48 (8): 803–12. doi:10.1111/j.1469-7610.2007.01756.x. PMID 17683452.
- ↑ Ozonoff S, Cathcart K (1998). "Effectiveness of a home program intervention for young children with autism". J Autism Dev Disord. 28 (1): 25–32. doi:10.1023/A:1026006818310. PMID 9546299.
- ↑ 13.0 13.1 Template:Cite paper
- ↑ Weber W, Newmark S (2007). "Complementary and alternative medical therapies for attention-deficit/hyperactivity disorder and autism". Pediatr Clin North Am. 54 (6): 983–1006. doi:10.1016/j.pcl.2007.09.006. PMID 18061787.
- ↑ Kasari C, Freeman S, Paparella T (2006). "Joint attention and symbolic play in young children with autism: a randomized controlled intervention study". J Child Psychol Psychiatry. 47 (6): 611–20. doi:10.1111/j.1469-7610.2005.01567.x. PMID 16712638. Erratum. J Child Psychol Psychiatry 48 (5): 523. doi:10.1111/j.1469-7610.2007.01768.x
- ↑ Gulsrud AC, Kasari C, Freeman S, Paparella T (2007). "Children with autism's response to novel stimuli while participating in interventions targeting joint attention or symbolic play skills". Autism. 11 (6): 535–46. doi:10.1177/1362361307083255. PMID 17947289.
- ↑ Matson JL, Matson ML, Rivet TT (2007). "Social-skills treatments for children with autism spectrum disorders: an overview". Behav Modif. 31 (5): 682–707. doi:10.1177/0145445507301650. PMID 17699124.
- ↑ Bellini S, Peters JK, Benner L, Hopf A (2007). "A meta-analysis of school-based social skills interventions for children with autism spectrum disorders". Remedial Spec Educ. 28 (3): 153–62.
- ↑ Rao PA, Beidel DC, Murray MJ (2007). "Social skills interventions for children with Asperger's syndrome or high-functioning autism: a review and recommendations". J Autism Dev Disord. doi:10.1007/s10803-007-0402-4. PMID 17641962.
- ↑ Rogers SJ, Ozonoff S (2005). "Annotation: what do we know about sensory dysfunction in autism? A critical review of the empirical evidence". J Child Psychol Psychiatry. 46 (12): 1255–68. doi:10.1111/j.1469-7610.2005.01431.x. PMID 16313426.
- ↑ "Sensory integrative therapy". Research Autism. Retrieved 2007-10-08.
- ↑ Baranek GT (2002). "Efficacy of sensory and motor interventions for children with autism". J Autism Dev Disord. 32 (5): 397–422. doi:10.1023/A:1020541906063. PMID 12463517.
- ↑ Schaaf RC, Miller LJ (2005). "Occupational therapy using a sensory integrative approach for children with developmental disabilities". Ment Retard Dev Disabil Res Rev. 11 (2): 143–8. doi:10.1002/mrdd.20067. PMID 15977314.
- ↑ Nimer J, Lundahl B (2007). "Animal-assisted therapy: a meta-analysis". Anthrozoos. 20 (3): 225–38. doi:10.2752/089279307X224773.
- ↑ Lori Marino, Scott O. Lilienfeld (2007). "Dolphin-Assisted Therapy: more flawed data and more flawed conclusions". Anthrozoos. 20 (3): 239–49. doi:10.2752/089279307X224782.
- ↑ el Kaliouby R, Picard R, Baron-Cohen S (2006). "Affective computing and autism". Ann N Y Acad Sci. 1093: 228–48. doi:10.1196/annals.1382.016. PMID 17312261.
- ↑ Scolnick B (2005). "Effects of electroencephalogram biofeedback with Asperger's syndrome". Int J Rehabil Res. 28 (2): 159–63. PMID 15900187.
- ↑ Kaufman BN (1995). Son-Rise: the Miracle Continues. HJ Kramer. ISBN 0915811618.
- ↑ Williams KR, Wishart JG (2003). "The Son-Rise Program intervention for autism: an investigation into family experiences". J Intellect Disabil Res. 47 (4–5): 291–9. doi:10.1046/j.1365-2788.2003.00491.x. PMID 12787161.
- ↑ Williams KR (2006). "The Son-Rise Program intervention for autism: prerequisites for evaluation". Autism. 10 (1): 86–102. doi:10.1177/1362361306062012. PMID 16522712.
- ↑ American Academy of Pediatrics. Committee on Children with Disabilities (1999). "The treatment of neurologically impaired children using patterning". Pediatrics. 104 (5): 1149–51. PMID 10545565.
- ↑ McConachie H, Diggle T (2007). "Parent implemented early intervention for young children with autism spectrum disorder: a systematic review". J Eval Clin Pract. 13 (1): 120–9. doi:10.1111/j.1365-2753.2006.00674.x. PMID 17286734.
- ↑ Tonge B, Brereton A, Kiomall M, Mackinnon A, King N, Rinehart N (2006). "Effects on parental mental health of an education and skills training program for parents of young children with autism: a randomized controlled trial". J Am Acad Child Adolesc Psychiatry. 45 (5): 561–9. doi:10.1097/01.chi.0000205701.48324.26. PMID 16670650.