Behavioral Therapies: Key Interventions in ASD
This is the first in a three-part series on behavioral interventions for autism spectrum disorders. Here, we discuss early intensive behavioral programs, such as Applied Behavior Analysis, and the evidence supporting their use. Part 2 will focus on Pivotal Response Training, a behavioral program featuring a more child-led approach. Part 3 will examine how Cognitive Behavioral Therapy has been adapted for use in higher-functioning, older individuals with autism.
Parents of children diagnosed with an autism spectrum disorder (ASD) are told that early intervention is crucial. Their next question naturally is: "What kind of intervention?"
Programs vary widely, but most include some kind of behavioral treatment. The reason for this is that there is a great deal of solid evidence that early intensive behavioral intervention is effective for children with ASD. 1,2,3
What is "Behavioral Therapy"?
Parents of most children are familiar with behavioral methods of some kind. Many typical child-rearing practices are based on behavioral principles. Giving stickers to encourage positive behavior, giving timeouts as a consequence for negative behavior, and ignoring a tantrum you believe is a cry for attention are all practices based on the belief that you can mold behavior by rewarding desired behaviors and punishing or ignoring negative ones.
In general, behavioral therapies involve carefully observing current behaviors and then targeting specific ones for change. Therapists employ various techniques to increase positive or decrease negative behavior, and constantly collect data on success and failure. That way it is clear whether the child is making progress. If not, the therapists can adjust their approach.
ASD, the Brain, and Behavioral Therapy
Children on the autism spectrum often need help with language, social interaction, and a variety of challenging behaviors from head-banging to tantrums to elopement (that is, running off). This is probably because brain structure, function, and chemistry are not typical in people with ASD. 4,5,6,7
Some researchers have suggested that a lack of social motivation underlies many of these children's deficits.1 This would help explain why they do not look into the eyes of others or focus on human faces and voices as often as typical people do.8,9 It would also help explain why they often fail to develop “joint attention,” that is, looking at or pointing to an object (like a toy or a puppy), making eye contact with a caregiver to indicate shared interest and enjoyment, and then looking back at the object together.
Social blindness likely leads to a cascade of problems because the brain is waiting for important input resulting from early social interaction and the imitation that is a part of it.10 When it doesn't get it, a child may not gain language, learn to read emotions, pick up social gestures, or come to understand the give and take of social relationships.
Fortunately, we have begun to understand that a brain that has been injured or is not developing properly can be influenced to begin to repair itself. The reorganization of connections in the brain that occurs during learning is a key part of this process.11 Therefore, behavioral interventions used to treat ASD may not just change outward behaviors, but may actually help rewire the brain.
In Early Behavioral Intervention, Brain Plasticity, and the Prevention of Autism Spectrum Disorder, Geraldine Dawson, Chief Science Officer of Autism Speaks, describes how early intensive behavioral treatments can help "guide brain and behavioral development back toward a normal pathway." 1
For example, if a toddler with autism is uninterested in social interaction, preferring to look at inanimate objects rather than at people, a behavioral therapist can help that toddler learn to find pleasure or reward in gazing at a human face. The more social interaction becomes valued, the more eye gaze, joint attention, and other fundamental social skills can be nurtured, encouraged, and built upon, getting development back on track.
Applied Behavior Analysis (ABA) and Discrete Trial Training (DTT)
There are a number of behavioral approaches, and they can become a confusing alphabet soup to those unfamiliar with them: ABA, DTT, PRT, and CBT, just to name a few. In this article, we’ll focus on Applied Behavior Analysis and Discrete Trial Training.
Applied Behavior Analysis, or ABA, is the most well-known behavioral intervention. In truth, ABA is something of an umbrella term, with several specific approaches falling under the general heading.
One of these is Discrete Trial Training (DTT), the most deliberate, purest form of ABA. DTT breaks skills or behaviors down into tiny pieces, making a child's success with each piece more likely. It is often used when a therapist wants to teach a new skill or behavior, or encourage one that does not happen very often.
What does this look like in practice?
First, the therapist identifies areas for intervention. Maybe a child is in a world of his own, engaging in repetitive behaviors such as spinning the wheel on a toy over and over again, and not paying attention to people or imitating them. One goal might be to use DTT to encourage imitation.
Usually, the therapist sits across a table from the child in a quiet space. In a single discrete trial, she encourages imitation by rewarding the child for touching his nose when she touches hers, perhaps by giving praise, a sticker, or a goldfish cracker. If the child doesn’t touch his nose, the therapist may gently prompt him. For example, she might take his hand and help him touch his nose. The therapist carefully records every detail: What the desired behavior was, whether the child did it, whether he needed a prompt, and what reward was given. Then she starts the entire process over again.
Each time through is one discrete trial, and each trial generally takes less than half a minute. After many discrete trials, the therapist will have a lot of information about whether the child is doing better than before, and which rewards seem to work best for him. As skills are gained, she can target new and more complex behaviors for intervention.
ABA is a key feature of most successful intensive early intervention programs. In her article, Geraldine Dawson lists a number of additional features, including:
- A comprehensive curriculum focusing on imitation, language, toy play, social interaction, motor, and adaptive behavior
- Sensitivity to developmental sequence (i.e. how skills build on one another)
- Behavioral strategies for reducing interfering behaviors
- Involvement of parents
- Gradual transition to more naturalistic environments
- Highly trained staff
- Supervisory and review mechanisms
- Intensive delivery of treatment (25 hours per week for at least 2 years) started by age 2-4.
When all the correct elements are in place, she writes, "results are remarkable for up to 50% of children."1
Getting the Therapy
As many families know, getting an ABA program in place for a child can be a challenge. Intensive programs can be time-consuming and expensive. In the U.S., even if a family has medical insurance, it may not cover the treatment. (This is why advocates all over the U.S. are fighting for insurance coverage of ABA, state by state.) In addition, in many areas there are not enough trained ABA therapists available for all the families that need services.
On a more positive note, many early intervention programs, whether home or school based, include elements of ABA or DTT. These also often draw on other key approaches, some of which are more child-led and less structured and restrictive than DTT. In a future article, we’ll discuss some of these alternative approaches, including Pivotal Response Training.
Resources in the United States
- Autism Speaks’ State Autism Insurance Reform Initiatives – learn about the status of autism insurance reform, which often focuses on coverage for ABA, in your state.
- Breakthrough in ABA Insurance Coverage -- report on an important legal decision that may clear the way for broader coverage of ABA by insurance companies.
- Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Development and psychopathology, 20(3), 775-803. View Abstract
- National Research Council, Committee on Educational Interventions for Children with Autism. (2001). Educating children with autism.National Academy Press. View Online Book
- National Autism Center. (2009). National standards report: Addressing the need for evidence-based practice guidelines for autism spectrum disorders. Randolph, Massachusetts: Author. View Report
- Pelphrey, K. A., & Carter, E. J. (2008). Charting the typical and atypical development of the social brain. Development and psychopathology, 20(4), 1081-1102. View Abstract
- Minshew, N. J., & Keller, T. A. (2010). The nature of brain dysfunction in autism: Functional brain imaging studies. Current opinion in neurology, 23(2), 124-130. View Abstract
- Kaiser, M. D., Hudac, C. M., Shultz, S., Lee, S. M., Cheung, C., Berken, A. M., et al. (2010). Neural signatures of autism. Proceedings of the National Academy of Sciences of the United States of America, 107(49), 21223-21228. View Abstract
- Chugani, D. C. (2012). Neuroimaging and neurochemistry of autism. Pediatric clinics of North America, 59(1), 63-73, x. View Abstract
- Jones, W., Carr, K., & Klin, A. (2008). Absence of preferential looking to the eyes of approaching adults predicts level of social disability in 2-year-old toddlers with autism spectrum disorder. Archives of General Psychiatry, 65(8), 946-954. View Abstract
- Osterling, J. A., Dawson, G., & Munson, J. A. (2002). Early recognition of 1-year-old infants with autism spectrum disorder versus mental retardation. Development and psychopathology, 14(2), 239-251. View Abstract
- Greenough, W. T., Black, J. E., & Wallace, C. S. (1987). Experience and brain development. Child development, 58(3), 539-559.
- Kleim, J. A. (2011). Neural plasticity and neurorehabilitation: Teaching the new brain old tricks. Journal of communication disorders, 44(5), 521-528. View Abstract