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Back to Subjects - Psychology

Programs for the Treatment of Autism

Programs for the Treatment of Autism Autism is a pervasive developmental disorder first termed by a man by the name of Kanner in 1943. He described a group of children as having severe language, behavior, and social interaction difficulties. These descriptors are what have come to be the core elements of autism today. Autism is characterized in the Diagnostic and Statistical Manual (4th ed.) by a continuum of abnormal development in social interaction and communication combined with a restricted repertoire of activities and interests. Children with autism are typically diagnosed by the age of two, with the prognosis generally being poor. The American Psychiatric Association’s 1994 estimated prevalence is about 1 per 1,000 individuals with males being diagnosed 3 times more than females. However, females are more likely than males to function in the mental retardation range (Gresham et al., 1999). Currently there is no known “cure” for autism. Therefore, in the following composition I am going to discuss some of the methods designed to manage the behavior of individuals with autism. The first program I am going to discuss is a project that was conducted by Lovaas beginning in 1970 called the UCLA Young Autism Project (YAP). The goal of this project was to increase behavioral functioning in children with autism by the use of simple commands (e.g. “Sit down,” “Look at me”). During the treatment, aggressive and self-stimulatory behaviors were either ignored or reacted to with a contingent physical and/or verbal punishment such as a slap on the thigh and/or a loud “No!” while alternative behaviors were reinforced (Gresham et al, 1999). The research design used in this project was a quasi-experimental design. The participants were not randomly assigned, but were coordinated into groups of 19 (Experimental, Control 1, and Control 2). Both children in the experimental group and control 1 received intensive one-to-one treatment beginning at average ages of 34.6 and 40.9 months respectively and continuing for two or more years. Children in the experimental group received at least 40 hours of treatment per week, whereas children in control 1 received 10 hours or less per week. Children in control 2 were not treated by the YAP personnel, but were given an unspecified form of treatment (Gresham et al., 1999). At the end of the project, 47% of the children in the experimental group were reported as having “recovered.” This indicating that their IQ scores were in the normal range (M=7, Range=94-120), they had passed the first grade in a regular education classroom, and they showed continuing increases in social, emotional, and educational functioning. Lovaas also reported that the school staff described these children as indistinguishable from their normal peers. No children from control 1 and only one child from control 2 reached this point of “recovery” (Gresham et al., 1999). Although the YAP appears to have been successful, there are many methodological issues to be considered. Most importantly is the lack of random selection, being a threat to both internal and external validity. For example, we cannot prove that the improvements were a direct cause of the treatment and had nothing to do with the children being from the same area. This study has not been able to be replicated, leaving even more questions about the study’s effectiveness and efficiency. Ethical issues also need to be taken into account. Would it be right to put children in a control group with no treatment if we know they will fare worse without it? Though the finding that discrete trail training can create normal functioning may be controversial, this does not mean that the program was of absolutely no benefit. The use of this type of treatment has been shown to be helpful in teaching children discriminations among stimuli (Gresham et al., 1999). This program is only one of many designed to aid in the training of individuals with autism. Another project that has received much attention is the program for the Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH). This program was first conducted by the Department of Psychiatry at the University of North Carolina in 1971. And in 1972 became the state organization mandated to serve children with autism and their families. In 1979 the mandate was extended to include adolescence and adults as well. The goal of the program is to combine the expertise of both the professional and the parent to develop the child’s vocational, social, and living skills through the use of visual prompts or cues in the environment (Gresham et al., 1999). The TEACCH model believes that behavioral difficulties are due to the individual’s inability to understand and successfully cope with their environment; therefore, there is a focus on making alterations in the environment to accommodate the child’s deficits in addition to developing new skills. An example of this is the way TEACCH takes advantage of students’ strengths in visual processing by using schedules, work charts, and overall organization to accommodate for the auditory deficits in many children with autism. Although children with autism may have many similar deficits, every child is different; thus, individualized assessment strategies, both formal and informal, are utilized as a basis for treatment. In determining the particular strategies for each individual, cognitive and behavioral therapies are the preferred forms of treatment (Van Bourgondien & Schopler, 1996). Overall, studies of the efficacy of the TEACCH program have shown positive results, however, as in the YAP studies, methodological issues were a concern. One study by Schopler et al. done in 1982 reported that of individuals with autism who underwent treatment through the TEACCH program, only 7% were institutionalized. A significantly lessened amount compared to rates of 39-74% in the 1960’s. However, government policies about the institutionalization of disabled individuals also started to change in the 1960’s. This leaves the question of whether this decrease in institutionalization was due to the treatment or the government policies (Gresham et al. 1999). A more recent study (Ozonoff & Cathcart, 1998) tested the effectiveness of a home-based TEACCH program. In this program the children in the experimental and control groups were matched rather than randomized as in the YAP. And there was no supervision of the program in the home to guarantee that the correct procedures were being used. These studies show that the TEACCH program may be effective in improving the symptoms of autism, but, as with most research, cannot tell us with complete accuracy (Gresham et al., 1999). The final program I am going to discuss, LEAP (Learning Experiences: an Alternative Program), is a less well known model. This program began in 1982 as a federally funded program serving young children as well as typical children ages 3 to 5 and was one of the first early intervention programs that focused on inclusion (Gresham et al., 1999). There are five key features of LEAP that are laid out by Strain and Hoyson. These are as follows: First, it is an individualized program. As in TEACCH individual objectives and strategies for treatment are planned for each child. Second, LEAP relies heavily on data. Data is collected in several areas including IEP objectives, social interactions, and classroom conduct. This data is then used to make decisions on whether teaching strategies should be maintaining, changing, or discontinuing strategies. Third, there is a focus on generalization. The IEPs used in LEAP are written to promote learning in all settings. Fourth, child participation is widely encouraged. Children are given every opportunity possible to respond to aspect of teaching, including that of peers. The typically developing children are also encouraged to initiate communication with the autistic children. And the fifth key element is family participation. LEAP advocates parent behavioral skills training that teaches basic behavior management and effective strategies for teaching these children (Strain & Hoyson, 2000). There have been no concrete studies done that support the efficacy of the LEAP. Though, many studies have shown the effectiveness of many of the aspects of LEAP, such as, parental or peer involvement. So, it would be expected that LEAP would result in improved learning. Although all of the methods I have described so far have included some form of behavior management, different medications have also been thought to be effective in improving behavior in autistic individuals. One of the core elements of autism, as in obsessive-compulsive disorder (OCD), is repetitive thoughts and behaviors. Likewise, abnormalities in serotonin function have also been identified in both disorders. Therefore, McDougle et al. describe studies noting the responses in individuals with autism to the five serotonin reuptake inhibitors (SRIs), clomipramine, fluvoxamine, fluoxetine, sertraline, and paroxetine, used today for the treatment of the behaviors of OCD patients. The studies, however, have offered mixed results. There have been only three published controlled studies involving clomipramine in children and adolescents with autism and one study involving fluvoxamine in adults. All three of the studies found the SRI to be effective in repetitive behaviors, as well as aggression, self-injurious behavior, and impaired social relatedness. Other controlled (unpublished) and open-label studies suggest that SRIs are not well tolerated and of limited efficacy in younger (prepubertal) autistic children as compared with adolescents and adults. On many accounts the SRIs had adverse side effects, but on the other hand, many individuals benefited from the SRIs (McDougle et al, 2000). Because of these varied results, much research is left to be done on the effects of SRIs on individuals with autism. With all the recent focus on autism, there has been a lot that we have learned over the years. We have come to understand that intensive interventions can be extremely effective, students do best in a structured and predictable environment, generalization must occur, outcomes are better when parents are involved in treatment, and that different children benefit from different strategies. Although this information has been very helpful, there is a lot we still don’t know. We know that individualized assessment strategies are best, but we do not yet know the best way to accommodate for individual needs. We do not know what factors (child, family, cultural, etc.) are best at determining what treatment procedure is best. Much of what we don’t know for sure is due to poor research. Agreed, much of the research is helpful, but it has not given us definite answers, which is a hard task in research. Schreibman has come up with several features of research that should be looked at when determining effectiveness. Included in these are 1. appropriate control groups and/or conditions, 2. well selected and specified populations, 3. appropriate and comprehensive diagnostic assessment of the populations, 4. appropriate randomized assignment, 5. were the treatment procedures described in the study actually used as intended?, and 6. comprehensive assessment strategies (Schreibman, 2000). These are all components of research that are important, but may or may not have been used, leaving the results of many of the studies invalid and/or unreliable. As you can see, there is a good deal to be done in the treatment research for autism. Yet the progress we have made to date has been substantial and gives us good reason to be optimistic for the future. Careful, well-established, well-controlled intervention studies will surely lead to improved programs for children with autism and their families. It is only through directed research by investigators in many different laboratories that the challenges we face can be adequately addressed. These children deserve the effective and efficient treatment programs such research will surely provide. Bibliography: Gresham, F. M., Beebe-Frankenberger, M. E., & MacMillan, D. L. (1999). A selective review of treatments for children with autism: Description and methodological considerations. School Psychology Review, 28 (4), 559-575. Hardman, M. L., Drew, C. J., & Egan M. W. (1999). Human exceptionality: Society, school, and family (6th ed.). Boston, Toronto, & Tokyo: Allyn and Bacon. McDougle, C. J., Kresch, L. E., & Posey, D. J. (2000). Repetitive thoughts and behavior in pervasive developmental disorders: Treatment with serotonin reuptake inhibitors. Journal of Autism and Developmental Disorders, 30 (5), 427-434. Schreibman, L. (2000). Intensive behavioral/psychoeducational treatments for autism: research needs and future directions. Journal of Autism and Developmental Disorders, 30 (5), 373-377. Strain, P. S., & Hoyson, M. (2000). The need for longitudinal, intensive social skill intervention: LEAP follow-up outcomes for children with autism. Topics in Early Childhood Special Education, 20 (2), 116-?. Van Bourgondien, M.E., & Schopler, E. (1996). Interventions for adults with autism. Journal of Rehabilitation, 62, 65-71.

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