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Educational and Behavioral Therapies

Interactive Autism Network at Kennedy Krieger Institute

Photo of childEducational and behavioral approaches are often a core feature of the overall treatment plan for children with an Autism Spectrum Disorder (ASD).  There are many different strategies currently being used, and new ones are being promoted on a regular basis. Many of these interventions differ not just in their implementation, but also in their philosophical approach to treating children with an ASD.

Limited evidence-based research is available for most of the behavioral and/or educational based programs. These approaches are particularly difficult to study using traditional research methods. For one thing, a classroom or therapist's office is a far cry from a laboratory setting. It is difficult to control for the many factors that can interfere with or bias research results. It is also often difficult to exactly reproduce any single intervention across settings.

One exception to this frustrating lack of evidence is the growing amount of research supporting the use of early intensive intervention programs for children with ASD. Such programs generally involve many hours of therapy each week for children between the ages of 2 and 7.

What Are Families Using?

As science continues to search for answers, parents move forward, trying what is available. There are a few standard approaches that almost every child receives while other treatments wax and wane in popularity. Reviewing the findings of Greene et al.,1  we can see that the top five interventions which could be considered "educational or behavioral" currently being used in the U.S. for children with ASD include Speech Therapy, Visual Schedules, Applied Behavioral Analysis (ABA), Social Stories, and the Picture Exchange Communication System (PECS).

All of these interventions are used by more than one-quarter of families with children with ASD. Speech therapy is the most common at 75%. Other popular behavioral and educational approaches include Cognitive/Behavioral Therapy, Discrete Trial Training (including Lovaas Therapy), Music therapy, Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH), Floortime, and Augmentative and Alternative Communication Systems. Each of these is used by more than 10% of families.

What Do We Know?

We know one thing for certain: early intensive intervention can change the outcome for young children with ASD. 2,3,4,5

Two major theoretical approaches dominate the early intervention scene: a behavioral approach and a developmental, relationship-based approach. 6

Behavioral Approaches

Applied Behavior Analysis, or ABA, is the most well known of the behavioral approaches. 7   Such programs focus on encouraging (or reinforcing) positive behaviors while discouraging negative ones. Practitioners carefully assess whether a child has been rewarded for any negative behaviors, and work to ensure that this no longer happens. They then work to establish new behaviors using a variety of methods, including discrete trial training. A child, for example, may be directed to hand his therapist a pencil. If he does, he will receive a reward --perhaps praise and a sticker or goldfish cracker. If he doesn't, he won't get the reward, but a prompt of some kind --such as the therapist moving his hand to the pencil. (In the past, physical punishments --called aversives-- were used to extinguish unwanted behaviors. Such practices are no longer considered acceptable.) 8

Many studies have shown that ABA and similar behavioral interventions can improve intelligence test scores, language skills, and academic performance of young children with ASD. 9,10,11,12,13   Some studies have also shown some measure of improvement in behavior 14  or personal and social skills, while others have not. 15,16   One issue has been generalization --that is, there has not been much evidence to show that children can transfer the skills they have learned through behavioral interventions to contexts outside the setting in which skills are acquired. 17

Many children taking part in these programs make significant strides.  It is clear at this point, however, that such interventions do not result ina great number of affected children achieving "normal" developmental status, 18,19,20   as was once claimed. 21

Developmental Approaches

Developmental interventions take a different tack. The most well known of these is Dr. Stanley Greenspan's Developmental, Individual-Difference, Relationship Based (DIR) model, of which Floortime is a major part.

"Development" refers to the process of acquiring skills in stages, from simpler to more complex. (For example, a child must babble sounds before he can say words, conquer words before he can utter phrases.) In Greenspan's view, the area of development where children with ASDs are most impacted is that involving higher order thinking and relating, from shared attention, to back and forth interactions, to problem solving, all the way to abstract thought. Floortime is a means to move a child up this developmental ladder. 22,23   An adult follows the child's lead to engage in play that will hopefully provide opportunities for connection, and therefore, to ever more complex emotional and social relating. If a child were lining up trains, for instance, an adult might get on the floor right beside them and line up trains, too, trying to catch the child's interest and his glance...and to share his pleasure or his frustration.

Unfortunately, we have little evidence to prove this approach is effective at present. Says the American Academy of Pediatrics: "Preliminary data are promising in terms of showing overall improvement. However, additional studies that include the use of control groups are needed to better assess this intervention model."24

The Best of Both Worlds: Overlapping Models

Although the behavioral and developmental viewpoints are far apart, in theoretical terms, there is also "considerable overlap between and across the various models." 25   For example, "naturalistic" behavioral strategies are more child-centered than the original ABA model, and Pivotal Response Training is behaviorally based, but attempts to address core issues for people with ASDs, such as the motivation to relate socially. 26   As in developmental approaches, the hope is that improvements in this core area will lead to improvements in many areas.

As time has gone on, many programs have evolved to include the best of both worlds: the intensive, behavioral focus of the ABA model and the relationship-rich, child-led focus of the Greenspan model.

Conclusion

Beyond the specific nature of any one approach, there are many other factors that may influence the outcomes of early intervention programs, such as location (home-based vs. center-based), duration and intensity of therapy, the experience of the provider, and the involvement of parents. In addition, characteristics of the child (such as age, symptoms, and severity of the disorder) also affect the potential benefits of therapy. Despite the many unknowns, most care providers believe that the earlier the child begins intensive intervention, the better the outcome. 27

Given the diversity of the spectrum and the unique combination of challenges and strengths observed for each child, it is reasonable to believe that, just as for other treatment categories, no single educational or behavioral approach is going to prove helpful for every child. This takes us back to the urgent need to distinguish meaningful subtypes of autism. What is truly needed is to find out which treatments work best on which symptoms for children with which specific type of ASD.

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References: 
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  2. Hurth, J., Shaw, E., Izeman, S.G., Whaley, K., & Rogers, S.J. (1999). Areas of agreement about effective practices among programs serving young children with autism spectrum disorders. Infants & Young Children, 12(2), 17-26.
  3. U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.
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  15. Reed, P., Osborne, L.A., & Corness, M. (2006). Brief report: Relative effectiveness of different home-based behavioral approaches to early teaching intervention. Journal of Autism and Developmental Disorders, epublished ahead of print December 19, 2006. PMID: 17180714  Abstract
  16. Smith, T., Groen, A.D., & Wynn, J.W. (2000). Randomized trial of intensive early intervention for children with pervasive developmental disorder. American Journal on Mental Retardation, 105(4), 269-285.  Abstract
  17. Horner, R.H., Carr, E.G., Strain, P.S., Todd, A.W., & Reed, H.K.  (2002). Problem behavior interventions for young children with autism: A research synthesis.  Journal of Autism and Developmental Disorders, 32(5), 423-446.  Abstract
  18. Shea, V. (2004). A perspective on the research literature related to early intensive behavioral intervention (Lovaas) for young children with autism. Autism, 8(4), 349-67.  Abstract
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  20. Boyd, R.D., & Corley, M.J. (2001). Outcome survey of early intensive behavioral intervention for young children with autism in a community setting. Autism, 5(4), 430-441.  Abstract
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  23. Greenspan, S.I., & Wieder, S. (1997). Developmental patterns and outcomes in infants and children with disorders in relating and communicating: A chart review of 200 cases of children with autistic spectrum diagnoses. Journal of Developmental and Learning Disorders, 1, 87-141.
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  26. Koegel, R.L., Koegel, L.K., & McNerney, E.K. (2001). Pivotal areas of intervention for autism. Journal of Clinical Child Psychology, 30(1), 19-32.  Abstract
  27. American Academy of Pediatrics - Committee on Children with Disabilities. (2001). Technical report: The pediatrician's role in the diagnosis and management of autistic specctrum disorder in children. Pediatrics, 107(5), 1221-1226.  Abstract