Transcript Treatments for Autism Spectrum Disorders

Introduction
 The diagnosis of an Autism Spectrum Disorder
presents parents and clinicians with a veritable
maze of programs and therapies.
 What is out there?
 Which programs are best for my child/student?
 What are the pros and cons?
1. What will the role of the clinician (OT, PT, SLP)
be in implementing this program or therapy?
2. For the next few minutes we will look at an
overview of the most standard and popular
treatment programs and therapies for
individuals on the Autism Spectrum.
Treatments for Core Symptoms
 Treatments for Autism Spectrum Disorders can be
divided into two categories:
 Treatments for Core Symptoms which address
behavioral, developmental and educational needs
specific to autism.
 Other therapies such as Occupational, Physical,
or Speech Therapy that while essential to the
treatment of Autism is not exclusive of other
disorders such as developmental delays or
cerebral palsy.
Applied Behavioral Analysis
 This treatment program (ABA) is based on the
principles of positive reinforcement of B.F.
Skinner.
 Simply, it is the repetitive use of positive
reinforcement to teach specific skills and
decrease inappropriate behaviors.
 What is occurring in the child’s environment to
cause negative behaviors?
ABA Three Step Procedure
 Antecedent: The verbal or physical stimulus such
as a command or request.
 Resulting Behavioral response to stimulus or a
lack of response
 Consequence: the positive reinforcement or no
response for inappropriate behavior
ABA Intervention
 ABA is not synonymous with Discrete Trial
Training. DTT was developed by Dr. O. Ivar
Lovass. DTT is a strategy used in ABA
 In ABA, skills are broken down into small,
discrete tasks which are taught using prompts,
which are faded out gradually as a skill is
mastered.
 Students are positively reinforced with either
verbal praise or something tangible that he/she
finds rewarding.
 ABA programs are carried out at school or in the
home with a one on one aide
 The goal is the carryover of the skills to other
environments.
 Facilitated play with peers is also part of this
program.
 The ABA provider is responsible for data
collection and analysis.
 Providers must be board certified behavior
analysts. The provider is responsible for writing
and managing the program. Individual
“Trainers”, who are not necessarily board certified
provide the daily intervention.
 Sessions last between 2-3 hours with 10-15 minute
breaks at the end of each hour for incidental
teaching and play time.
 Intervention requires 35-40 hours per week with
families encouraged to use these techniques daily.
 While punishments are not generally used, a
therapist may intervene if a child is hurting
himself by non-injurious methods such as a light
spray of water in the face.
 ABA is reputed by many to be the most successful
therapy available.
 “ We found that 48% of all children showed rapid
learning and achieved average post-treatment
scores, and at age 7 were succeeding in regular
classrooms.”(Lovaas, 1987; McEachin, Smith and
Lovaas, 1993)
 The data collected on a daily basis allows parents
and team members to closely follow the students
progress.
 40 hours of intervention a week is often
considered to be just too much for many families.
 The cost is prohibitive. While some schools will
provide ABA, few will pay the cost of 40 hours per
week of one on one intervention for “just” one
child.
 Critics suggest that ABA can create an
“emotionless, robotic” child who has difficulty
carrying over skills to a natural environment.
The Therapist’s Role in ABA
 ABA is usually paired with speech therapy in early
intervention. The SLP must be aware of the specific
plan for each child and regularly communicate the the
ABA therapist.
 Speech Therapy, Occupational Therapy, and Physical
Therapy are often areas where the child can generalize
and practice skills learned in ABA Therapy.
 Each discipline brings to the ABA program differing
goals and objectives in terms of communication
modalities, positioning and sensory needs.
Pivotal Response Treatment
 This program was developed at the University of
California at Santa Barbara by Dr. Robert Koegel,
Dr. Lynn Kern Koegel, and Dr. Laura Shrubman.
 It is also referred to as the Natural Language
Paradigm and is based on ABA principles.
Pivotal Response Treatment
 The goal of this intervention is to teach language,
decrease inappropriate behaviors, and increase
social skills and academics. The focus on
intervention is on those skills pivotal to the
normal development of many other skills and
behaviors.
 Pivotal skills include: communication skills, play,
social skills, and the ability to monitor one’s own
behavior.
 PRT differs from ABA in that it is child directed
 PRT is provided by psychologists, SPED teachers,
Speech Pathologists, and other providers
specifically trained in PRT.
 PRT Certification is offered through the Koegel
Autism Center:
 PRT programs require at least 25 hours of
intervention weekly.
 All family members are encouraged to use PVT
methods consistently with the student.
 Some disadvantages include: financing, finding
local providers and trying to live a “normal”
family life while constantly in “therapy mode”.
The Therapist’s Role in PRT
 As in ABA, the SLP, OT, and PT work with the PRT
provider in developing a treatment program. The PRT
provider should provide suggestions to other
professionals on targeting pivotal behaviors.
Communication between therapists and families is a
must.
 All providers should focus on using the same
prompting strategies.
 PRT blends especially well with Speech Therapy as it
can be adapted to teach a variety of skills including
symbolic and sociodramatic play and joint attention.
Verbal Behavior
 This program uses Skinner’s analysis of language
as a system to teach language and modify
behaviors.
 It encourages the student to learn language by
developing a connection between a word and its
meaning.
 Verbal Behavior is based on the idea that the way
we talk influences how sensitive or aware we are
of changes to our environment.
 The intervention first focuses on using language
to request or “mands”.
 Then the focus turns to naming or labeling
referred to in the program as “Tact”
 Finally the focus of treatment moves to “IntraVerbal Communication” which includes
understanding and use of wh-questions and
conversation.
Verbal Behavior and the Clinician’s
role
Floor Time
 This approach is based
on the Developmental
Individual Difference
Model from Dr. Stanley
Greenspan.
 Floor Time is simply the
idea that a child’s
communication skills
can be improved by
building on his/her
strengths while playing
together on the floor.
Floor Time:
The overall goal
 Six developmental milestones
 Self regulation and interest in the world
 Intimacy or a special love for others
 Two way communication
 Complex communication
 Emotional ideas
 Emotional thinking
Implementation
 The therapist enters the child’s activities and
follows the child’s leads in play and guides the
child in expanding his/her interactions.
 Parents are instructed on how to move the child
to more complicated interactions which are
referred to as “Opening and Closing
Communication Circles.
 Speech, motor, and cognitive skills are addressed
“Through a synthesized emphases on emotional
development.
 Floor Time is sometimes used in conjuction with ABA.
 Intervention is delivered in a low stimulus environment
from 2-5 hours per day with the child’s family using the
principles in daily life.
 Interdisciplinary Council on Developmental Learning
Disorders
 Greespan, S., & Weider, S. (1998). “The Child with Special
Needs”. Reading, MA: Addison-Wesley.
Floortime: Playtime
for the Clinician
 The principles of Floortime can easily be included
in the therapy techniques of Speech, OT and PT.
 Floortime allows for a fun, naturally reinforcing
therapy environment.
 SLP’s, OT’s, and PT’s already employ a variety of
play therapy techniques in their interventions.
Relationship Development
Intervention
 Developed by Dr. Steven
Gutstien
 It is a parent based program
using the following “Dynamic
Intelligence Objectives”
Dynamic Intelligence Objectives
 Emotional Referencing: the
use of emotional feedback to
learn from the experiences of
others
 Social Coordination: the
ability to observe and
continually regulate ones
behavior in order to
participate in spontaneous
relationships involving
collaboration and exchange of
emotion.
Dynamic Intelligence Objectives
 Declarative Language: using language and non-
verbal communication to express curiosity and
inviting others to interact and share perceptions
and feelings and to corridinate one’s action with
others.
 Flexible Thinking: ability to adapt rapidly and
change strategies and alter plans based on
changing circumstances.
Dynamic Intelligence Objectives
 Relational Information Processing: the ability to
obtain meaning based on a larger context and
solving problems that have no clear right or
wrong answers.
 Foresight and Hindsight: the ability to reflect on
past experiences and anticipate potential future
scenarios.
Intervention
 In this program, the child begins working one on
one with the parent. Then another peer is added
who is at a similar level of relationship
development. As the child progresses, other
children are added to the group and the
environments are changed.
 The curriculum consists of six levels: Novice,
Apprentice, Challenger, Explorer, and Partner.
The program guides the child to develop
friendships, and show empathy.
Intervention
 Parents learn the program through training
seminars from an RDI certified consultant
Pros and Cons
 RDI is not considered a complete treatment
program.
 It is a program designed specifically for parent
implementation.
RDI: A Therapists Perspective
 Since RDI is meant for implementation by the
parent only, it would be important for the SLP, OT,
and PT to be aware of the principles of RDI and
the progress of the student in this intervention.
 Communication with parents and floor time
intervention specialist is vital to the development
of a multi-disciplinary team approach.
TEACCH
raining and ducation of utistic and Related
ommuni ation for andicapped Children
(TEACCH)
 Developed by Eric Schopler, PhD of the University
of North Carolina
 This is a highly structured program based on the
“Culture of Autism”.
Culture of Autism
 This term refers to the “relative strengths and
difficulties shared by people with autism and that
are relevant to how they learn”.
(
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Intervention
 In this approach, children are evaluated to
determine emergent skills and intervention is
designed to build on these skills.
 The intervention plan is developed for each
individual child to help plan activities and
experiences.
 The child refers to visual supports such as picture
schedules to help them predict and cope with
daily activities.
 The TEACCH program is for home or school
interventions.
 Training is available through TEACCH Centers in
North Carolina and by TEACCH trained
pshychologists, SPED Teachers and SLPS
Pros and Cons
 This program focuses on cultivation of the child’s
strengths and interests rather than focusing on
his/her deficits alone.
 The strengths of those with autism (visual skills,
recognizing details, and memory can become the
basis of successful adult functioning (Ohio’s
Parent Guide to Autism Spectrum Disorders –
Mesibov and Shea, 2006).
TEACCH and the Therapist
 SLPs, OTs, and PT’s can easily include TEACCH
procedures in their therapy sessions.
 Therapists can incorporate the use of schedules,
social stories and other techniques in their
therapy plans, encouraging skill generalization.
SCERTS
 Social Communication, Emotional Regulation,
and Transactional Support
 Developed by Barry Prizant, PhD., Amy Wetherby,
PhD, Emily Rubin and Amy Laurent
 SCERTS draws from other programs such as ABA,
Pivotal Response Treatment, TEACCH, Floor Time
and RDI.
SCERTS
 The main difference between SCERTS and ABA is
that SCERTS encourages child initiated
communication in daily life.
 SCERTS aim is to help the child achieve “Authentic
Progress”, which is defined as the ability to learn
and spontaneously carry over functional skills
into various settings and with many
communication partners.
The Focal Aspects of SCERTS
 Social Communication: spontaneous functional
communication, emotional expression and secure
and trusting relationships with others
 Emotional Regulation: the ability to maintain a
well-regulated emotional state and the ability to
cope with daily stresses.
 Transactional Support: development and
implementation of supports to assist
communication partners to adapt the
environment and provide the tools to enhance
learning(picture communication, written
schedules, sensory supports).
 Specific plans are developed to provide education
and emotional support for families and to
encourage teamwork among the intervention
team.
Intervention
 This program provides for
children with Autism to learn
with and from other children
who are good social and
language models
 Transitional supports
(environmental
accommodations) and
learning supports (picture
schedules or visual organizers)
 This program is usually provided in the school
settings by SCERTS trained professionals
Pros and Cons
 Unlike ABA, this program focuses on group
intervention rather than one on one treatment.
 Uses a multidisiciplinary team approach
 SCERTS is not an exclusive program and accepts
other educational models that the team deems
appropriate.
Therapist’s Perspective
 The SCERTS model is an interdisciplinary
approach. The model uses the knowledge base
and experience of general and special educators,
SLPs, OTs, PTs, and other professionals.
 Therapists should be familiar with SCERTS
principles and techniques and communication
with the SCERTS provider, parents other members
of the intervention team is critical to the success
of the program.
The Hanen Approach
 This approach is based on
the belief that parents
should be the child’s
language teachers, because
they have the strongest
bond and have many
opportunities to teach
language in the natural
contexts of daily living.
 Parents are trained by
Hanen certified SLPS.
The Hanen Approach
 Trained parents can then adapt the approach to
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meet the individual and unique needs of their
child.
Programs for Parents include:
“It Takes Two To Talk”-Hanen program for parents.
“More Than Words”- Hanen program for parents
of children with Autism Spectrum Disorders
“Target Word” – Hanen program for parents of
Late Talkers.
The Hanen Approach
 The Hanen Centre has also developed supports
for teachers (Learning Language and Loving It – A
Guide to Promoting
Children’s Social, Language, and Literacy
Development second edition – Weitzman and
Greenber, 2002).
Pros and Cons
 Parents are to be the sole providers for this
approach.
 It is not intended to be a curriculum
 It does not exclude of other educational models.
Integrated Play Groups
Integrated Play Groups
Pros and Cons
Play and Therapy!!
The Son-Rise Program
 The Son-Rise Program was developed by Barry
Neill Kaufman and his wife when their son Raun
was diagnosed as severely and incurably autistic.
 The program is a system of treatment and
education focusing on joining children instead of
working against them.
Principles of the Son-Rise Program
 Joining in the child’s repetitive and ritualistic
behaviors is considered the “key to unlocking the
mystery of these behaviors”, facilitating eyecontact, social behaviors and the inclusion of
others in play.
 Utilizing a child’s own motivations advances
learning and builds the foundation for education
and skill acquisition.
 Teaching through interactive play results in
effective and meaningful socialization and
communication.
Principles of the Son-Rise Program
 The program encourages providers and parents to
teach with enthusiasm and to employ a nonjudgemental attitude.
 This approach considers the parent to be the most
important and best resource. It encourages the
creation of a distraction free work and play
environment to facilitate optimal learning.
Intervention
 Intervention is provided through parent-training
at one the Autism Treatment Centers of America.
 Parents are the primary providers, however they
can include family and friends in the intervention
process.
 The Son-Rise Program combines effectively with
other complementary therapies (ie. Biomedical
interventions, sensory integration, diet and
Auditory Integration therapies).
Pros and Cons
 The cost in terms of finances and time required
for daily intervention may be prohibitive for many
parents.
 The Son-Rise Program has come under fire for
“promoting” a cure for autism.
 It is interesting to note that this program is not
even listed in the Ohio Parent’s Guide to Autism
Spectrum Disorders or on the Autism Speaks
Website.
 www.autismtreatmentcenterofamerica.com
The Role of other therapies in the
Son-Rise program
Resources
 Autism Speaks
 Ohio Center for Autism and Low Incidence
 SLP-ABA Journal
 Koegel Autism Center
Resources and Credits
 Interdisciplinary Council on Developmental Learning
Disorders
 Greenspan,S.,& Weider, S. (1998). “The Child with Special
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Needs.” Reading, MA: Addison-Wesley
Relationship Development Intervention
TEACCH
SCERTS
The Hanen Approach
 “American Maze”, Dale Wilkins. Used by permission 2/10
In Summary
 There are many, many different approaches to
treating Autism Spectrum Disorders.
 This list is by no means comprehensive.
 Parents and therapists should engage in careful
research before committing to any specific
program.
The End of the Maze!!