Treatments for Autism
There is no single treatment protocol for all children with autism,
but most individuals respond best to highly structured behavioral
programs. The National Institute of Child Health and Human
Development lists Applied Behavior Analysis among the recommended
treatment methods for autism spectrum disorders. Some of the most
common interventions are Applied Behavior Analysis (ABA), Floortime
Therapy, Gluten Free, Casein Free Diet (GFCF). Speech Therapy,
Occupational Therapy, PECS, SCERTS, Sensory Integration Therapy,
Relationship Development Intervention, Verbal Behavior Intervention,
and the school-based TEAACH method.
Applied Behavioral Analysis (ABA)
Behavior analysis is a natural science of behavior that was originally
described by B.F. Skinner in the 1930's. The principles and methods
of behavior analysis have been applied effectively in many arenas.
For example, methods that use the principle of positive reinforcement
to strengthen a behavior 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 behavior 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 behaviors 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 learner¹s 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 customized
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.
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Floortime
Developed by child psychiatrist Stanley Greenspan, Floortime is a
treatment method and a philosophy for interacting with autistic
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 autistic 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 synthesized 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.
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Gluten Free, Casein Free Diet (GFCF)
Many families of children with autism spectrum disorders are interested
in dietary and nutritional interventions that might help some of their
children's symptoms. Removal of gluten (a protein found in barley, rye,
oats, and wheat) and casein (a protein found in dairy products), in what
is known as a Gluten Free, Casein Free diet, or GFCF, is a popular
dietary treatment for symptoms of autism. It is based on the
hypothesis that these proteins are absorbed differently in children
with autism spectrum disorders and act like false opiate-like chemicals
in the brain. The hypothesis is not based on an allergic response.
Neither the hypothesis nor the effectiveness of this dietary intervention
has been demonstrated in scientific studies to date. Studies are
ongoing in a number of centers. However, many families report that
dietary elimination of gluten and casein has helped regulate bowel
habits, sleep, activity, habitual behaviors and enhance overall progress
in their individual child. No specific laboratory tests can predict
which children might be observed by their families to have a positive
response to dietary intervention. For that reason, many families elect
a trial of dietary restriction with careful observation by the family
and intervention team.
A trial of dietary restriction requires attention to basic nutritional
guidelines. Dairy products are the most common source of calcium and
vitamin D in young children in the U.S. Many young children depend on
dairy products for a balanced protein intake. Alternative sources of
these nutrients require substitution of other food and beverage products
with attention to nutritional content rather than solely as a milk
substitute beverage. Substitution of gluten free products requires
attention to the overall fiber and vitamin content of a child's diet.
Vitamin and supplement use may have both positive effects and side
effects. Consultation with a dietitian or physician should be considered
and can be helpful to families in the determination of healthy
application of a GFCF diet. This may be especially true for children
who are picky eaters.
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Occupational Therapy
Occupational Therapy can benefit a person with autism by attempting to
improve the quality of life for the individual. The aim is to maintain,
improve, or introduce skills that allow an individual to participate as
independently as possible in meaningful life activities. Coping skills,
fine motor skills, play skills, self help skills, and socialization are
all targeted areas to be addressed.
Through occupational therapy methods, a person with autism can be aided
both at home and within the school setting by teaching activities
including dressing, feeding, toilet training, grooming, social skills,
fine motor and visual skills that assist in writing and scissor use,
gross motor coordination to help the individual ride a bike or walk
properly, and visual perceptual skills needed for reading and writing.
Occupational therapy is usually part of a collaborative effort of
medical and educational professionals, as well as parents and other
family members. Through such collaboration a person with autism can
move towards the appropriate social, play and learning skills needed
to function successfully in everyday life.
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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 “vocalize” a desire,
observation, or feeling. These pictures can be purchased in a manualized
book, 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.
A formalized 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 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. It is thought that by allowing children to express themselves
non-verbally, the children are less frustrated and non-desirable behavior
including tantrums is reduced.
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Relationship Development Intervention (RDI)
Relationship Development Intervention (RDI) Based on the work of
psychologist Steven Gutstein , Relationship Development Intervention
(RDI) focuses on improving the long term quality of life for all
individuals on the spectrum. The RDI program is a parent- based
treatment that focuses on the core problems of gaining friendships,
feeling empathy , expressing love and being able to share experiences
with others. Dr's Gutstein program is said to be based on extensive
research in typical development and translates research findings into
a systematic clinical approach. His 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:
1) Emotional Referencing: The ability to use an emotional feedback
system to learn from the subjective experiences of others.
2) 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.
3) 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.
4) Flexible thinking: The ability to rapidly adapt, change strategies
and alter plans based upon changing circumstances.
5) Relational Information Processing: The ability to obtain meaning
based upon the larger context. Solving problems that have no
"right-and-wrong" solutions.
6) 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 utilized and generalized. The program is said to be
able to be started easily and implemented into regular, daily
activities that enrich family life.
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The SCERTS® Model
(Prizant, Wetherby, Rubin, Rydell & Laurent, 2006)
The SCERTS® Model is a comprehensive, team-based, multidisciplinary
model for enhancing abilities in Social Communication and Emotional
Regulation, and implementing Transactional Supports for children and
older individuals with autism spectrum disorders (ASD) and their families.
SCERTS is not an exclusive approach, in that it provides a framework in
which practices and strategies from other approaches may be integrated,
such as Positive Behavioral Supports (ABA), visual supports, sensory
supports, augmentative and alternative communication (AAC), and Social
Stories® . The SCERTS model can be used with individuals across a wide
range of ages and developmental abilities. It was developed by Barry
Prizant, Amy Wetherby, Emily Rubin, Amy Laurent and Patrick Rydell,
a multidisciplinary team of clinicians, researchers, and educators who
have more than 100 years experience, and have published extensively in
the field of autism.
The focus on Social Communication involves developing spontaneous,
functional communication and secure, trusting relationships with
children and adults. Emotional Regulation involves enhancing the ability
to maintain a well-regulated emotional state to be most available for
learning and interacting. Transactional Support includes supporting children,
their families, and professionals to maximize learning, positive
relationships and successful social experiences across home, school
and community settings. The SCERTS Model, emphasizes the importance of
child initiated communication in natural as well as semi-structured
activities for a broad range of purposes such as requesting, greeting,
expressing emotions and protesting/refusing. Objectives for the child are
developmentally appropriate and may target both verbal and non-verbal forms
of communication. SCERTS is a collaborative educational model in that
families and educators work together to identify and develop strategies
to successfully engage the child in meaningful daily activities.
SCERTS differs from the focus of "traditional" ABA that typically targets
children's responses in adult directed discrete trials with the use of
behavioral techniques to teach language. In contrast, the focus of the
SCERTS model is on promoting child-initiated communication in everyday
activities. In philosophy and practice, SCERTS is closer to "contemporary"
ABA practices such as Pivotal Response Training and Incidental Teaching,
which use natural activities in a variety of social situations, as well as
semi-structured teaching in social routines. In contrast to most ABA
practices, SCERTS relies extensively on visual supports (e.g., photos,
picture symbols) for supporting Social Communication and Emotional
Regulation. SCERTS is based on child development research and research
on the core challenges in autism, in a manner similar to Floortime and RDI.
The SCERTS Model is most concerned with helping persons with autism to
achieve “Authentic Progress”, which is defined as the ability to learn and
apply functional skills in a variety of settings and with a variety of
partners. All of a child's partners, including educators, therapists,
parents, siblings and peers potentially play an important role in a SCERTS
Model Program, because activities in which goals and objectives are
addressed include daily routines at home and school, as well as special
therapies and activities that have the potential to enhance abilities
in independent and self-help skills, with a particular emphasis on
social communication and emotional regulation. For example, mealtimes
across home and school settings may have the same objectives that
include using pictures, words and/or gestures to select food items,
to observe and imitate partners in order to benefit from their social
models, and to respond to a partners' attempts to support a good emotional
state that results in sustained attention and active participation.
Objectives in play and social skills may also be identified and targeted
at school with classmates, as well as at home with siblings or cousins.
A plan to support a child's emotional regulation across each day is also
developed based on a child's needs. The plan may include regularly
scheduled exercise and “regulating” breaks, opportunities for sensory
and motor activities, and a plan used by all partners to modify learning
environments. Partners also become expert at reading a child's signals of
emotional dysregulation and responding with appropriate support as needed
to maximize attention and learning and to prevent escalation into more
problematic behavior (e.g., offering deep pressure, simplifying difficult
tasks. clarifying tasks through the use of visuals – e.g., "2 more then
we are all done").
When observing activities in the SCERTS Model, there is always a high
priority placed on:
1) children initiating as well as responding to partner's verbal and
nonverbal communication;
2) children actively participating in activities with adults and peers,
with an emphasis on joyful, shared positive emotional experience, and the
development of trusting relationships,
3) partners implementing a range of interpersonal and learning supports
to help a child be most available for learning and engaging,
4) partners being highly responsive and supportive in a flexible manner
that depends on the child's emotional state, distractions in the setting,
the child's success in the activity and the need for appropriate levels
of support to actively participate.
In SCERTS, there is a great emphasis on child initiation in natural as well
as semi-structured activities for a very broad range of communicative
functions (e.g., greeting, requesting comfort, protesting/refusing,
calling). Objectives are developmentally sequenced, including nonverbal
(e.g., gestures) as well as verbal communication and are selected based
on a child's functional needs in daily activities as determined by the
child's team. Thus, the focus of the SCERTS model on promoting
child-initiated communication in everyday activities differs from the
focus of "traditional" ABA, that typically targets children's responses
in adult directed Discrete Trials with the use of behavioral techniques
to teach language. In Philosophy and practice, SCERTS is closer to
"contemporary" ABA practices such as Pivotal Response Training and
Incidental Teaching, which use natural activities in a variety of social
situations with a variety of partners (peers and different adults), as
well as semi-structured teaching in social routines. SCERTS also relies
on visual supports (e.g., photos, picture symbols) extensively for
supporting Social Communication and Emotional Regulation to a greater
extent than ABA, and is based on child development research and research
on the core challenges in autism, in a manner similar to Floortime and RDI.
For further information, including a detailed list of FAQ's and research
support for the SCERTS Model, go to
www.SCERTS.com.
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Sensory Integration Therapy
Sensory Integration is the process through which the brain organizes and
interprets external stimuli such as movement, touch, smell, sight and
sound. Autistic 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 hyposensitive
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 neurosensory
and neuromotor 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
autistic 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 organizes sensory
information. The therapy often requires activities that consist of full
body movements utilizing 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.
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Speech Therapy
The communications problems of autistic children vary to some degree and
may depend on the intellectual and social development of the individual.
Some may be completely unable to speak whereas others have well-developed
vocabularies and can speak at length on topics that interest them. Any
attempt at therapy must begin with an individual assessment of the child's
language abilities by a trained speech and language pathologist.
Though some autistic 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 memorized. Some autistic 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.
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TEACCH
TEACCH (Training and Education of Autistic and Related Communication
Handicapped Children) is a special education program that is tailored
to the autistic 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 training
them to perform in acceptable and appropriate ways.
Building on the fact that autistic children are often visual learners,
TEACCH brings visual clarity to the learning process in order to build
receptiveness, understanding, organization and independence. The
children work in a highly structured environment which may include
physical organization 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 organized.
It is believed that structure for autistic 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.
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Verbal Behavior Intervention
Verbal Behavior Intervention is often seen as an adjunct to Applied
Behavioral Analysis (ABA). Though both are based on theories developed
by Skinner there are differences in concept. In the late 1950s and early
60's when Dr. Ivar Lovaas was developing his ABA principles, Skinner
published Verbal Behavior which detailed a functional analysis of language.
He explained that language could be grouped into a set of units, with each
operant serving a different function. The primary verbal operants are what
Skinner termed echoics, mands, tacts, and intraverbals.
The function of a mand is to request or obtain what is wanted. For
example, the child learns to say the word "cookie" when he is interested
in obtaining a cookie. When given the cookie, the word is reinforced and
will be used again in the same context. There is an emphasis on "function"
of language(VB) as opposed to form (Lovaas-based). In a VB program the
child is taught to ask for the cookie anyway he can( vocally, sign language,
etc.) If the child can echo the word he will be motivated to do so to
obtain the desired object. In a Lovaas-based ABA program the child might
say the word cookie when seeing a picture and is thus labeling the item.
This form of language is called a "tact." Critics of Lovaas say children
are taught to label many words but often cannot use them in functional or
spontaneous ways. Another operant, "intraverbals" describes verbal behavior
that is under the control of other verbal behavior and is strengthened by
social reinforcement. Intraverbals are the way people engage in
conversational language. They are responses to the language of another
person, usually answers to "wh-" questions.. If you say to the child
"I'm baking..." and the child finishes the sentence with "Cookies,"
that's an intraverbal fill-in. Also, if you say, "What's something you
bake?" (with no cookie present) and the child says, "Cookies," that's an
intraverbal (wh- question). Intraverbals allow children to discuss stimuli
that aren't present, which describes most conversation and is a goal of
Verbal Behavior Intervention.
Both ABA and VB use similar formats to work with children. It is said that
VB attempts to capture a child's motivation to develop a connection between
the value of a word and the word itself. Many therapists are now using
techniques of VB to bridge some of the gaps seen in ABA.
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