Interventions_for_Children_with_Autistic_Spectrum_Disorder

Interventions for children with autistic spectrum disorder This essay aims to evaluate the approaches used to aid in the support of individuals with autistic spectrum disorder. The main approaches to be covered in this essay are ‘The Applied Behavioural Analysis’ (ABA) approach (more commonly referred to as the Lovaas approach) the TEACCH approach and the Son-Rise programme. The literature suggests that the most beneficial interventions are those which are initiated at an early stage, especially for those with a primary focus on children (Roth et al. 2009, p.177). Autism was noted primarily in the early 40’s, with Kanner (1943, cited in Lovaas, 1987, p.3) as; “children who exhibit (a) serious failure to develop relationships with other people before 30 months of age, (b) problems in development of normal language, (c) ritualistic and obsessional behaviors ("insistence on sameness"), and (d) potential for normal intelligence”. This definition inherently shows the difficulties associated with the ways in which professionals and family members can work with the individual to aid them in their early developmental years. The Lovaas approach began its initial empirical work in the early 70’s which was a behavioural programme designed to take full advantage of behavioural treatment benefits by treating children during most of their ‘waking’ hours and for a lengthy duration (Ibid, p.3). The Applied Behavioural Analysis approach: The Lovaas Approach: Lovass (1987) devised a programme in which the primary focus lay on language growth, social abilities of interactions and the way in which a child was integrated into a school setting, to be known as the UCLA Young Autism Project (Ibid, p.4). Initially the programme focuses on the ability of the child to aid themselves in their development (self-help) and come to understand the meaning of particular forms of language and ways in which play becomes an acceptable form of interaction (guiding the child away from aggressive, non-acceptable play amongst their peers and supporting their understanding of sensory integration) (Roth et al. 2009, p. 191). The second part of the intervention allows the child to explore expressive forms of language and further play with peers. Further advanced stages implement the use of the programme at home or in the school environment allowing an academic understanding to develop by observation, which permits an inclusion into mainstream environments (Ibid) and for the home environment to benefit also (when there is not always one on one professional support). Parents are always heavily involved with treatment implementation (Sheinkopf & Siegel, 1998, p. 16) again reinforcing collaboration between individuals. Behaviour shaping is also implemented to try and reduce undesirable aggressive or self-stimulatory behaviours (time-out methods etc.). The programme is highly inclusive of family, teachers and health professionals throughout, which is beneficial to the child. If the child is able to flourish within everyday environments, then the facilitation of his or her transitional progression through the early years is made simpler. There are high levels of collaboration between all members due to the integrative approach of the programme. The programme has been deemed one of the most successful for treating individuals with autism; “The EIBI model developed by Lovaas (1981, 2003) (hereafter referred to as the Lovaas approach.) has arguably been the most significant influence on the instructional methodology employed by behavioral practitioners in recent years”. Carr and Firth (2005, p.18). Critically, the method has received high levels of support. Approximately 50% of individuals (children) who take part in a behavioural adjustment programme have shown significant increases in IQ and been enabled to continue their education in regular classrooms without the need for intensive one of one support throughout (Weiss, 1999, p.3). If these interventions are introduced before the age of 4 and lasting at least 2 years, then the significance of their improvement is dramatic. Weiss does note however, that the studies from which these findings are taken vary in experimental control and reliability. The Lovaas approach has enabled children to reach a normal educational and functional level by the approximate age of seven. Although some may not develop such levels of function, it is suggested that their levels of language and the decrease in inappropriate behaviours are significant (The National Autistic Society, 2001). However, the cost of intervention is expensive, with programmes reaching £25,000 a year for implementation (Ibid). The Lovaas approach has received criticism is relation to the intensity of the programme in regards to children of such young age (Sheinkopf & Siegel, 1998, p. 15) with intensive integration covering an average of 40 hours (Weiss, 1999, p.4). This is high in comparison to an average school week for a five year old spanning 30 hours, and the intensity of the programme may be too much in terms of mental stimulation for young individuals with autism. From professional observation, it is a common occurrence for children to become disruptive when over-tired or overstimulated. Autistic children are at risk of becoming not only difficult in terms of their ability to integrate and progress in a ‘normal’ environment, but by behavioural problems induced by overstimulation. Gresham and MacMillan (1998, p.5) suggest that; “Based on rebuttals to criticisms of their program, the EIP( EIP – Early Intervention Programme, another name used for Applied Behavioural Analysis.) authors seem unwilling to admit any methodological flaws in the sampling, design, and analysis of data of the EIP. It is recommended that parents and fair hearing officers adopt an attitude of healthy skepticism before proceeding to an unqualified endorsement of the EIP as a treatment for autism.” They further suggest that the original work of Lovaas, was in fact a quasi-experiment and that methodological issues with his data arise. With such flaws, one could question the validity of the intervention strategies of the Lovaas approach. However, although the support for ABA programmes in general is fairly substantial there does appear to be ongoing debate regarding it’s suitability for early intervention (Sheinkopf & Siegel, 1998, p. 15). Although, there does appear to be an overall significance in treatment effects and the parental feedback appears positive (The National Autistic Society, 2001). The TEACCH (Treatment and Education of Autistic and Communication related handicapped CHildren) programme: TEACCH was a programme developed in the early 70’s and there are contemporary (revised) versions currently in use across many different countries and is one of the several frameworks suggested by the Autism Society of America (ASA) (Roth et al. 2009, p.187). The programme was the result of a five-year project researching autistic educational methods and has led the way for further developmental programmes designed at augmenting the autistic child into a normal environment (TEACCH, n.d.). It is noted by researchers, that children who are allowed a structured approach to teaching are more likely to benefit from the effects, after a large research project was found to show a substantial progress in educational, cognitive, linguistic, social and behavioural status (Rutter and Bartak, 1973). They also noted an overall suggestion; that for autistic children to succeed in an educational environment, large amounts of specific teaching aimed at the integration of the child is needed. The TEACCH programme facilitates the use of visually mediated learning and utilises a prosthetic structuring of the school environment to assist in behaviour shaping (Jordan, Jones, & Murray, 1998, p.6). This prosthetic environment allows autistic children to live and work in an environment which is designed to try and minimise some of the inherent effects of development in a ‘normal’ environment (Jordan, Jones, & Murray, 1998, p.80). However, this will cause difficulties for the child when entering environments which are not designed to cater for their needs, such as a play gym or sports club for children. If the child becomes accustomed to having all his/her needs met by the environment, it may make integration into an outside environment (a place away from school, the treatment centres or home) a traumatic event for the child. TEACCH addresses some of the autism difficulties related to organisation, auditory processing deficiency, issues with memory and to aid in transitional periods between one task and another (Ibid) which may aid in this transference from the designed to normal environment. There is an emphasis or structure, often visually, to allow the child to always foresee what is coming next and when. This reduces the need for verbal commands which the autistic child may have difficulties in processing. TEACCH is a very collaborative method of treatment, however in the UK it is found more commonly amongst school rather than pre-school settings (Ibid). Difficulties herein arise with the time that the treatment is started. With much research suggesting the earlier the implementation the better (Weiss, 1999, p.3), particularly at the latest age of four, then the TEACCH programme in the UK is not making use of early developmental years. Starting a treatment programme once the child has already entered into mainstream school will not only be disruptive and over-stimulating for the child, but will also dislocate the other children in the class. If the programme is started after a few weeks of regular school, issues may arise with alienation from other pupils. By introducing the programme at an early age, the child will never be aware that there was ‘another way’ and it is suggested that this will allow for a much smoother developmental transition. This does appear to be the case in the US, where the TEACCH programme is implemented in the pre-school years. The TEACCH approach has a high level of integration, with its use facilitated through to adult life (Jordan, Jones, & Murray, 1998, p.80). Jordan, Jones and Murray, (1998, p.6) note that at the time of publishing, eight examples of studies on the TEACCH approach had been found, although only one had a comparison control group. This makes an analysis of the effectiveness of the programme difficult to achieve. Again, as with the Lovaas approach, there appears to be a high level of parental satisfaction. This may be due to the TEACCH method of guiding the autistic child to be able to function independently of adults. This will be a huge benefit to parents and guardians of autistic children, as with time the one on one time needed whilst they are in the home environment can decrease, allowing the child to progress through the early years just as any child would, or even their sibling/s. However, Mesibov (1998) carried put an independent review of the use of the TEACCH approach and found that although the research shows a general satisfaction amongst parents, this cannot be used as scientific evidence for its efficiency. Collaboration between parents, teachers and programme facilitators is high due to the way that the programme integrates into everyday life. The Son-Rise Programme: The Son-Rise (SR) programme is unique in its development in the fact that it was designed by two parents, Barry Neil Kaufman and Samahria Lyte Kaufman, for use with their own autistic son in 1974 (Autism Treatment Centre, 2011a). The programme aims to be a; “...child-centered and home-based environment, with emphasis on love and acceptance to the child.” (Tso, Hui, Shan Lee & Tsang, 2008, p.2). The programme is designed to stimulate the senses known as scotopic sensitivity training and has a ‘gentle’ approach to integrating education and the autistic child’s development. The creators of the Son-Rise programme felt that the ABA programmes were in fact pushing the autistic child away from them instead of allowing for an emotional development to be facilitated (Autism Treatment Centre. 2011b). One such claim of the SR programme is that it can ‘cure’ or allow recovery from Autism (Howlin, 2003, p.252). The basis of the SR programme is that the child is battling with a distressing and bizarre environment and that they are attempting to shut out everything distressing to them. It is assumed that this causes a lack of brain stimulation and has a knock on effect for the distressing element of the disorder. The SR programme works with this deficit by encouraging pleasurable social interactions and to allow the environment around them to develop into a more alluring surrounding to them than engaging in the ritualistic repetitive behaviours often associated with autism (Howlin, 2005, p.109). The programme is very much aimed at the parents, involving them in their child’s progression. The great benefit of this approach is that the child is not always with an alien individual during treatment, as their own parents are often the ones who begin the programme at home in a familiar environment for the child. Environmental issues are thus kept to a minimum. From a professional perspective, children who suffer from a learning impairment of the autistic kind find strange faces a distressful occurrence, and they are much more relaxed and interactive when alone with parental figures. This would also mean the child is unaware that anything ‘abnormal’ is happening to them and should allow for them to become more involved naturally, as opposed to the regiment of a structured programme. Parents are in fact encouraged to engage in the ritualistic behaviours of the child, to try and find a connection, to ‘reach’ out to the child (Ibid). Parents are taught to recognise the ‘cues’ of their own child and respond appropriately to them. The Kaufman’s claim that their own son, who when diagnosed as autistic had an IQ of 30, gained a near genius IQ after 9,000 hours of treatment (Kaufman, 1982, cited in Howlin, 2005, p.109). In terms if the collaboration between professionals and parents, it appears low with the programme being home based, and the information required for intervention available online. This causes a lack of support for the parent, the risk that the parent implements something in an incorrect manner and also means that emotional drives in the parent may cause a reduction of the ‘gentle’ approach and mat result in negative reinforcement (punishment etc) which is not recommended in the SR programme. The transferability of the programme may cause issues, especially when parents are required to engage in ritualistic behaviour in public places. This may cause the child to become victimised or alienated. It appears that many of the evaluations of the SR approach are anecdotal in nature, reducing their scientific significance and questioning the methodology of investigation (Roth, et al. 2009, 194). Scientific investigation has shown that the SR approach often has more negative impacts on a family than positive, although as with other approaches, the parental evaluation appeared high (Williams & Wishart, 2003). It would also appear that when implementing the programme in home environments, they are often not put into practice as is described in the literature and by the founders (Williams, 2011). There also appears to be little or no literature available as to how a SR programme would be included during school hours. The SR programme would not be the most ideal programme for a ‘normal’ educational setting due to the ritualistic behaviour (rocking, sucking or repetitive sounds etc.,) inclusion in the programme. As a professional, advice is usually given against other children observing the inclusive behaviour as it can be confusing or even distressing for them, especially when an adult is seen to also be engaging in the behaviour. Summary: It would appear that the overall evaluative findings for the different approaches are lacking in scientific conclusions, often relying on observation of a few children or from the anecdotal reports of teachers and parents. As stated by Jordan, Jones, & Murray (1998, p.120) “Most approaches had some evidence of the effectiveness of what they did in terms of outcome, but this was extremely variable in quality in scientific terms. Some approaches seemed happy to rely on case studies of a few children, reported by the proponents of the approach, and this is clearly the weakest form of evidence.” The authors also note that communication between parties is poor and that the programmes are not integrative enough to allow a child to progress naturally through his or her early years. Roth et al. (2009, p.194) state that the SR programme has never been formally evaluated, and Carr and Firth (2005, p.18) state there is no evidence on the long term outcomes of behavioural approaches to autistic behaviour. If the approaches are to be evaluated, data would need to be gathered scientifically for equal variables across the board which would allow for correlation analysis to evaluate the outcomes on specific scales across the approaches. This is not only to find the ‘best’ in terms of effectiveness, but may be able to supply providers with the information needed to adapt their programmes to meet the deficit needs. Currently, from a professional opinion, the TEACCH appears the most effective in terms of integration across environments, although is still in need of further evaluation to allow consideration to be made regarding their effectiveness at supporting the autistic child from the early years, to young adulthood. References: Autism Treatment Centre. 2011a .The Son-Rise Programme. [online] Available at [Accessed 1 Feb 2011]. Autism Treatment Centre. 2011b. Introduction to Son-Rise. [online] Available at Accessed 1 Feb 2011]. Carr, J. E. and Firth, A. M. 2005. The verbal behavior approach to early and intensive behavioral intervention for autism: A call for additional empirical support. Journal of Early and Intensive Behavior Intervention, 2, pp.18–27. Gresham, F. M., and MacMillan, D. L. 1998. Early intervention project: Can its claims be substantiated and its effects replicated' Journal of Autism and Developmental Disorders, 28, pp.5–13. Howling P. 2003. Can early interventions alter the course of autism' Autism: Neural Basis and Treatment Possibilities, Novartis Foundation Symposium, 251, pp.250–258. Howlin, P. 2005. The effectiveness of interventions for children with autism. Journal of Neural Transmission, 69(Supplementum), pp.101–119. Jordan, R., Jones, G. and Murray, L. 1998. Educational Interventions for Children with Autism: A Literature Review of Recent and Current Research. Norwich: HMSO (DfEE Research Report 77). Lovaas, O. I. 1987. Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, pp.3–9. Mesibov, G. 1998. Formal and informal measures on the effectiveness of the TEACCH programme, Int. J. of Autism, 1, pp.25-35. Roth, I., et al. 2009. The Autism Spectrum in the 21st Century. Milton Keynes: The Open University. Rutter, M and Bartak, L. 1973. Special Educational Treatment of Autistic Children. Journal of Child Psychology and Psychiatry, 14, pp.241-270. Sheinkopf, S. J., and Siegel, B. 1998. Home-based treatment of young children with autism. Journal of Autism and Developmental Disorders, 28, pp.15-23. TEACCH. n.d. Research.[online] Available at [Accessed 31 January 2011]. Tso, A., Hui, B. K. M., Shan Lee, G. P., and Tsang, F. Y. 2008. A ‘Play-Love-Faith’ Learning Program for Children with Profound and Multiple Learning Difficulties.[online] Available at < http://www3.lys.edu.hk/~lys/lysweb/LYpaper.pdf> [Accessed 1 Feb 2011]. The National Autistic Society. 2001. Lovaas. [online] Available at