Early Intervention & Therapy. 

There is no single intervention for all children with Autism, but most individuals respond best to highly structured behavioural programs.

Some of the most common interventions are:

• Applied Behaviour Analysis (ABA)
• Floortime Therapy
• Speech Therapy
• Occupational Therapy
• PECS
• Sensory Integration Therapy
• Relationship Development Intervention
• Early Start Denver Model
• the school-based TEAACH method.

Further information can be found in the dedicated tabs on the left (top for some mobile users). Please select a tab to view the information.

Evaluating Claims. 

For the child with Autism, every moment counts. While there may be much that we still do not know or understand about Autism, we do know that the best outcomes are achieved through early intervention.

Fortunately, we are learning more effective and reliable ways of diagnosing Autism earlier and earlier, but the difficult question for parents and professional alike remains ‘how do we help’ or ‘what type of intervention.’

Today there are many, many approaches for the treatment of Autism. Those who promote or support many of these interventions make grand claims about effectiveness, some even suggest that they can cure Autism. However, there is often little solid evidence to support these claims.

With each intervention there is an associated cost; not only financially, but also in terms of time and effort. With so many interventions to choose from, parents and professionals need to invest their time, effort, and money wisely in those treatments that have been shown to produce the best, most long-lasting effects.

Each child is an individual, and will respond differently to intervention. There is no formula to predict which strategies or interventions will be most effective for a child; however, parents can maximise their chances of achieving the best outcomes by learning as much as possible about the intervention and thinking critically about the claims.

The following recommendations may be helpful in helping sort through the information.

Evidence of Treatment Effectiveness.

Just because a person has an advanced degree (M.D., Ph.D., M.Sc., etc.) does not mean that the treatment they support has been carefully evaluated and demonstrated effective. 

Information based on subjective evidence includes information based on someone’s personal perspective. This might include autobiographies, personal accounts, testimonials, anecdotes, rumours, uncorroborated self-reports, and opinions.  While this information can be useful to identify issues for further study, it should not be presented as the basis for evidence of treatment effectiveness.  Think about all of the adverts and posts on social media about fad diets. 

The claims of effectiveness of many of these types of “interventions” are based on self-report and sometimes even edited images, and we know that the majority of claims made cannot be justified.

• Be wary of interventions that use personal report or an accumulation of testimonials as the sole basis for demonstrating treatment effectiveness.

In contrast, objective evidence is information based on direct and repeated measurement.  Examples include measurements taken by instruments or machines (e.g. blood tests, blood pressure, MRI, EEG, etc.), standardised tests, and direct observational methods in which behavior is counted or quantified in some other way. 

When treatments are based on objective evidence you will be able to find clear descriptions of the behaviours or skills that were targeted for treatment, and the measurements used to assess change. 

Evaluation, verification, and replication of this information by others is encouraged in order to validate the success of the intervention.

• Look for interventions that rely on direct measurement to evaluate and support claims of effectiveness.

Of course, all interventions must begin somewhere. Even those interventions that today are supported by a wealth of evidence were at one point unsubstantiated. 

If as a parent you feel strongly about an intervention that does not seem to have a strong evidence-base, work with the provider or person implementing the intervention to clearly and objectively outline the aims of the intervention and systematically monitor progress.

• Be cautious of any provider who is hesitant or unable to objectively evaluate progress, or who suggests that having the intervention model independently evaluated is not important.

Resources to help with Evaluation.

Fortunately, there are a number of organisations who have devoted a great deal of time and effort into sifting through and summarising the research. Some useful online resources include:

• Research Autism
• TARGET
• ASAT
• Autism PDC

What else should I think through when considering different intervention options?

• What is the treatment?  What procedures are used and what is involved? Is this something my child will tolerate?
• What are the expected effects?  Specifically, what behaviours or skills can I expect to improve as a result of this treatment? If deciding to try the intervention, you will want to have a way of monitoring or detecting any changes in these skills.
• Who will administer, manage, or implement the treatment and how can I be sure that the person(s) providing the treatment are qualified? Try to make sure that the person is in no way misrepresenting their qualifications or experiences.
• How will the effects of the treatment on my child be evaluated?  How often? Again, be sure that the plan for evaluating matches the aim of the intervention.

• Is there much evidence to suggest that this intervention might be effective? What type of evidence is available; internet claims, parent report and testimonial, or research?
• If the treatment is proven effective, how long do the effects last? Are improvements observed for just a period of time until the next session or administration, or does the intervention impact sustained change?
• What are the potential costs or risks of implementing this treatment?
• What are the short-term negative side effects?
• What are the long-term negative side effects?
• What safeguards are in place if my child experiences negative side effects? Who will I contact and what support will be provided?
• Is there another treatment that is similarly effective but has fewer negative side effects?
• How long will we need to implement this treatment?

Applied Behavioural Analysis (ABA)

Behaviour analysis is a natural science of behaviour that was originally described by B.F. Skinner in the 1930’s.

The principles and methods of behaviour analysis have been applied effectively in many arenas. For example, methods that use the principle of positive reinforcement to strengthen a behaviour by arranging for it to be followed by something of value have been used to develop a wide range of skills in learners with and without disabilities.

Since the early 1960’s, hundreds of behaviour analysts have used positive reinforcement and other principles to build communication, play, social, academic, self-care, work, and community living skills and to reduce problem behaviours in learners with Autism of all ages.

Some ABA techniques involve instruction that is directed by adults in highly structured fashion, while others make use of the learner’s natural interests and follow his or her initiations.

Still others teach skills in the context of ongoing activities. All skills are broken down into small steps or components, and learners are provided many repeated opportunities to learn and practice skills in a variety of settings, with abundant positive reinforcement.

The goals of intervention as well as the specific types of instructions and reinforcers used are customised to the strengths and needs of the individual learner.

Performance is measured continuously by direct observation, and intervention is modified if the data show that the learner is not making satisfactory progress.

Regardless of the age of the learner with Autism, the goal of ABA intervention is to enable him or her to function as independently and successfully as possible in a variety of environments.

Floortime.

Developed by child psychiatrist Stanley Greenspan, Floortime is an intervention method and a philosophy for interacting with ASD children.

It is based on the premise that the child can increase and build a larger circle of interaction with an adult who meets the child at his current developmental level and who builds on the child’s particular strengths.

The goal in Floortime is to move the child through the six basic developmental milestones that must be mastered for emotional and intellectual growth. Greenspan describes the six rungs on the developmental ladder as:

• self regulation and interest in the world
• intimacy or a special love for the world of human relations
• two-way communication
• complex communication
• emotional ideas and
• emotional thinking

The child is challenged in moving naturally through these milestones as a result of sensory over- or under-reactions, processing difficulties, and/or poor control of physical responses.

In Floortime, the parent engages the child at a level the child currently enjoys, enters the child’s activities, and follows the child’s lead.

From a mutually shared engagement, the parent is instructed how to move the child toward more increasingly complex interactions, a process known as “opening and closing circles of communication.”

Floortime does not separate and focus on speech, motor, or cognitive skills but rather addresses these areas through a synthesised emphasis on emotional development.

The intervention is called Floortime because the parent gets down on the floor with the child to engage him at his level.

Speech Therapy.

The communications problems of ASD children vary to some degree and may depend on the intellectual and social development of the individual.

Any attempt at therapy must begin with an individual assessment of the child’s language abilities by a qualified speech and language therapist.

• Some may be completely unable to speak whereas others have well-developed vocabularies and can speak at length on topics that interest them.
• Though some ASD children have little or no problem with the pronunciation of words, most have difficulty effectively using language.
• Even those children who have no articulation problems exhibit difficulties in the pragmatic use of language such as knowing what to say, how to say it, and when to say it as well as how to interact socially with people.
• Many who speak often say things that have no content or information.
• Others repeat verbatim what they have heard (echolalia) or repeat irrelevant scripts they have memorised.
• Some ASD children speak in a high-pitched voice or use robotic sounding speech.

Two pre skills for language development are joint attention and social initiation. Joint attention involves an eye gaze and referential gestures such as pointing, showing and giving.

Children with autism lack social initiation such as questioning, make fewer utterance and fail to use language as a means of social initiation.

Though no one treatment is found to successfully improve communication, the best treatment begins early during the preschool years, is individually tailored, and involves parents along with professionals. The goal is always to improve useful communication.

For some verbal communication is realistic, for others gestured communication or communication through a symbol system such as picture boards can be attempted.

Periodic evaluations must be made to find the best approaches and to reestablish goals for the individual child.

Occupational Therapy.

Many children with ASD present with difficulties with fine motor and/or gross motor skills and sensory issues which affect their ability to engage in daily activities and roles.

Activities could include self-help skills such as doing up buttons or the development of good pencil skills which will then effect the person’s ability to engage in an occupation or activity such as dressing or drawing.

Roles would include the role of being a student or a friend. An inability to maintain good postural control, for example, would mean that the child would find it difficult to sit at a school desk for any length of time which would affect his ability to fulfil his role as a student.

Similarly, if the child has poor spatial awareness his body language towards his peers may put up barriers to developing friendships which affects his attempts to develop his role as a friend.

Thus Occupational Therapy assists the individual to develop the necessary physical skills, where needed, to make the engaging in activities or roles more accessible to them through individualised, specifically targeted programs

Picture Exchange Communication System (PECS).

PECS is a type of augmentative and alternative communication technique where individuals with little or no verbal ability learn to communicate using picture cards.

Children use these pictures to “vocalise” a desire, observation, or feeling.

These pictures can be purchased in a manual, or they can be made at home using images from newspapers, magazines or other books.

Since some people with Autism tend to learn visually, this type of communication technique has been shown to be effective at improving independent communication skills, leading in some cases to gains in spoken language.

Image credit SETBC.

A formalised training program is offered through a company called Pyramid Products, and this program takes the caregiver and child through different phases. However, this manual is not the only source of training and resources.

Images may be obtained through magazines, photos, or other media.

In Phase one, a communication trainer works with the child and their caregivers to help decide which images would be most motivating. For example, images of food may elicit the strongest response. Cards are then created (or provided through a pre-made book) with those images, and the trainer and the caregiver work with the child to help him or her discover that, by handing over the card, they can get the desired object.

In Phase two, the caregiver then moves farther away from the child when showing the picture, so that the child must actually come over and hand over the card to receive the food reward. This process engages the child’s ability to seek and obtain another person’s attention. In this way, a full vocabulary and methods for using these new words are taught to the affected individual.

In later phases, children are given more than one image so that they must decide which to use when requesting an item, and throughout the process the number of cards grows and thus the child’s ‘vocabulary’ also increases.

Over time, the child may develop the ability to use sentences, including phrases like “I want” to start off the sentence, and even use descriptors like “large” or “red”.

Throughout the process, which may take weeks, months or years, the caregiver gives constant feedback to the child.

Research has demonstrated that by increasing communication, the children are less frustrated and non-desirable behaviour including tantrums is reduced.

Sensory Integration Therapy.

Sensory Integration is the process through which the brain organises and interprets external stimuli such as movement, touch, smell, sight and sound.

ASD children often exhibit symptoms of Sensory Integration Dysfunction (SID) making it difficult for them to process information brought in through the senses.

Children can have mild, moderate or severe SID deficits manifesting in either increased (hypersensitivity) or decreased (hyposensitivity) to touch, sound, movement, etc. For example, a hypersensitive child may avoid being touched whereas a hypo-sensitive child will seek the stimulation of feeling objects and may enjoy being in tight places.

The goal of Sensory Integration Therapy is to facilitate the development of the nervous system’s ability to process sensory input in a more typical way.

Through integration the brain pulls together sensory messages and forms coherent information upon which to act. SIT uses neuro-sensory and neuro-motor exercises to improve the brain’s ability to repair itself.

When successful, it can improve attention, concentration, listening, comprehension, balance, coordination and impulsivity control in some children.

The evaluation and treatment of basic sensory integrative processes in the ASD child are usually performed by an occupational and/or physical therapist.

A specific program will be planned to provide sensory stimulation to the child, often in conjunction with purposeful muscle activities, to improve how the brain processes and organises sensory information.

The therapy often requires activities that consist of full body movements utilising different types of equipment. It is believed that SIT does not teach higher-level skills, but enhances the sensory processing abilities thus allowing the child to acquire them.

Relationship Development Intervention (RDI).

Relationship Development Intervention (RDI) is based on the work of psychologist Steven Gutstein. 

RDI is a parent-education programme based on the latest research on the brain, developmental psychology and autism that focuses on promoting and enhancing the child’s social and emotional understanding.

It focuses on the core problems of gaining friendships , feeling empathy , expressing love and being able to share experiences with others.

Dr Gutstein’s research found that individuals on the Autism spectrum seemed to lack certain abilities necessary for success in managing the real life environments that are dynamic and changing. He calls these abilities dynamic intelligence and describes six aspects as follows:

• Emotional Referencing: The ability to use an emotional feedback system to learn from the subjective experiences of others.
• Social Coordination: The ability to observe and continually regulate one’s behavior in order to participate in spontaneous relationships involving collaboration and exchange of emotions.
• Declarative Language: Using language and non-verbal communication to express curiosity, invite others to interact, share perceptions and feelings and coordinate your actions with others.
• Flexible Thinking: The ability to rapidly adapt, change strategies and alter plans based upon changing circumstances.
• Relational Information Processing: The ability to obtain meaning based upon the larger context. Solving problems that have no “right-and-wrong” solutions.
• Foresight and Hindsight: The ability to reflect on past experiences and anticipate potential future scenarios in a productive manner.

Dr Gutstein, who along with Dr. Rachelle Sheely, formed the Connections Center For Family and Personal Development based in Houston Texas in 1995, says, “We are challenging families and professionals to think beyond achieving mere functionality as a successful outcome for individuals with autism; our reference point for success in the RDI program is quality of life.”

The goal is social improvements as well as changes in flexible thinking, pragmatic communication, creative information processing and self- development.

The program offers training workshops for parents as well as several books that offer step-by step exercises building motivation so that skills will be utilised and generalised.

The program is said to be able to be started easily and implemented into regular, daily activities that enrich family life.

In a study in Texas, after 2.5 years on the Relationship Development Intervention (RDI)programme, 15% of children were still in special education classes,compared with 90% before going on the programme.

Early Start Denver Model (ESDM).

The Early Start Denver Model (ESDM) is a comprehensive behavioural early intervention approach for children with autism, ages 12 to 48 months. ESDM is a relationship-based intervention, and involves the parents and families.

At the heart of the ESDM is the empirical knowledge-base of infant-toddler learning and development and the effects of early autism. 

ESDM intervention can be provided in the home by trained therapists and parents during natural play and daily routines.

An Early Start for your Child with Autism  is a parent’s guide to using everyday activities to help kids connect, communicate, and learn. 

The aim of ESDM is to increase the rates of the development in all domains for children with ASD as it simultaneously aims to decrease the symptoms of autism.

In particular, this intervention focuses on boosting children’s social-emotional, cognitive, and language, as development in these domains is particularly affected by autism. 

ESDM also uses a data based approach and empirically supported teaching practices that have been found effective from research in applied behavior analysis.

ESDM fuses behavioural, relationship-based, and a developmental, play-based approach into an integrated whole that is completely individualised and yet standardised.

There is an ever-growing body of evidence to demonstrate that children as young as 18 months improve in cognitive and language skills, adaptive behaviour, and demonstrate fewer symptoms of Autism after ESDM intervention.

TEACCH.

TEACCH (Training and Education of Autistic and Related Communication Handicapped Children) is a special education program that is tailored to the ASD child’s individual needs based on general guidelines.

It dates back to the 1960’s when doctors Eric Schopler, R.J. Reichler and Ms Margaret Lansing were working with children with autism and constructed a means to gain control of the teaching setup so that independence could be fostered in the children.

What makes the TEACCH approach unique is that the focus is on the design of the physical, social and communicating environment. The environment is structured to accommodate the difficulties a child with autism has while teaching them to engage in acceptable and appropriate ways.

Building on the fact that ASD children are often visual learners, TEACCH brings visual clarity to the learning process in order to build receptiveness, understanding, organisation and independence.

The children work in a highly structured environment which may include physical organisation of furniture, clearly delineated activity areas, picture-based schedules and work systems, and instructional clarity.

The child is guided through a clear sequence of activities and thus aided to become more organised.

It is believed that structure for ASD children provides a strong base and framework for learning.

Though TEACCH does not specifically focus on social and communication skills as fully as other therapies it can be used along with such therapies to make them more effective.