Treatment of PDD/NOSOn the whole, children with PDDNOS share the social and communicative disabilities found in children with Autistic Disorder. They often need services or treatments similar to those provided to children with autism.
Traditional MethodsNo one therapy or method will work for all individuals with Autistic Disorder or PDDNOS. Many professionals and families will use a range of treatments simultaneously, including behavior modification, structured educational approaches, medications, speech therapy, occupational therapy, and counseling. These treatments promote more typical social and communication behavior and minimize negative behaviors (e.g., hyperactivity, meaningless, repetitive behavior, self-injury, aggressiveness) that interfere with the child's functioning and learning. There has been an increasing focus on treating preschool children with PDDNOS by working closely with family members to help the children cope with the problems encountered at home before they enter school. Many times, the earlier these children begin treatment, the better the outcome.
Addressing behavior issuesAs children with PDDNOS struggle to make sense of the many things that are confusing to them, they do best in an organized environment where rules and expectations are clear and consistent. The child's environment needs to be very structured and predictable.
Many times a behavior problem indicates that the child is trying to communicate something--confusion, frustration or fear. Think of the child's behavior problem as a message to be decoded. Try to determine the possible cause of the behavior. Has the child's routine or schedule changed recently? Has something new been introduced that may be distressing or confusing the child? When a child's communication skills improve, behavior problems often diminish--the child now has a means of expressing what is bothering him or her, without resorting to negative behavior.
The use of positive behavioral support strategies for these children has proved effective. It is important to remember that:
1. Programs should be designed on an individual basis, because children vary greatly in their disabilities and abilities. Treatment approaches that work in certain cases may not work in others.
2. Children with PDDNOS have difficulty generalizing from one situation to another. The skills they have learned in school tend not to be transferred to the home or other settings. It is very important to be consistent in the treatment of a problem across all areas of the child's life--school, community, and home. This encourages generalization of behavior changes.
3. A home-community-based approach, which trains parents and special education teachers to carry out positive behavioral support strategies, can be instrumental in achieving maximum results.
Appropriate educational programEducation is the primary tool for treating PDDNOS. Many children with PDDNOS experience the greatest difficulty in school, where demands for attention and impulse control are virtual requirements for success. Behavioral difficulties can prevent some children from adapting to the classroom. However, with appropriate educational help, a child with PDDNOS can succeed in school.
The most essential ingredient of a quality educational program is a knowledgeable teacher. Other elements of a quality educational program include: - structured, consistent, predictable classes with schedules and assignments posted and clearly explained;
- information presented visually as well as verbally;
- opportunities to interact with nondisabled peers who model appropriate language, social, and behavioral skills;
- a focus on improving a child's communications skills using tools such as communication devices;
- reduced class size and an appropriate seating arrangement to help the child with PDDNOS avoid distraction;
- modified curriculum based on the particular child's strengths and weaknesses;
- using a combination of positive behavioral supports and other educational interventions; and
- frequent and adequate communication among teachers, parents, and the primary care clinician
Behavioral and Communication Approaches The behaviors exhibited by children with autism are frequently the most troubling to parents and caregivers. These behaviors may be inappropriate, repetitive, aggressive and/or dangerous, and may include hand-flapping, finger-snapping, rocking, placing objects in one's mouth, and head-banging. Children with autism may engage in self-mutilation, such as eye-gouging or biting their arms; may show little or no sensitivity to burns or bruises; and may physically attack someone without provocation. The reasons for these behaviors are complex, but some professionals think that sensory integration issues contribute to them. Communication skills - both the spoken and written word - are also an issue for children with autism. They have difficulty understanding how communication works, and may have difficulty with reciprocal conversation. Many also have language difficulties, either being nonverbal throughout their lives or having delayed speech. Some children use language in unusual ways, such as repeating the words or sentences said to them (echolalia) or using only single words to communicate. Language difficulties may contribute to behavioral problems. Unable to use language to communicate his or her needs, a child with autism may resort to screaming. Many treatment approaches have been developed to address the range of social, language, sensory, and behavioral difficulties. These include Applied Behavioral Analysis (ABA); Discrete Trial Training (discrete trials); TEACCH; PECS; Floor Time; and Social Stories, and sensory integration. Applied Behavior Analysis - ABA Many of the interventions used to treat children with autism are based on the theory of applied behavior analysis (ABA) - that behavior rewarded is more likely to be repeated than behavior ignored. Although ABA is a theory, many people use the term to describe a specific treatment approach with subsets that include discrete trial training or Lovaas. While the terms discrete trial and Lovaas have been used interchangeably, only practitioners who are affiliated with Lovaas can be said to implement "Lovaas Therapy." In discrete trial training, every task given to the child consists of a request to perform a specific action, a response from the child, and a reaction from the therapist. It is not just about correcting behaviors but is designed to teach skills, from basic ones such as sleeping and dressing to more involved ones such as social interaction. Discrete trial training is an intensive approach. Children usually work for 30 to 40 hours a week one-on-one with a trained professional. Tasks are broken down into short simple pieces, or trials. When a task has been successfully completed, a reward is offered, reinforcing the behavior or task. This method is not without controversy. Some practitioners feel it is emotionally too difficult for a child with autism, that the time requirement of 30 to 40 hours a week is too intensive and intrusive on family life; and that while it may change a particular behavior, it does not prepare a child with autism to respond to new situations. However, research has shown that ABA techniques show consistent results in teaching new skills and behaviors to children with autism. TEACCH The first statewide program for treatment and services for people with autism, TEACCH (Treatment and Education of Autistic and Related Communication Handicapped Children) was developed at the School of Medicine at the University of North Carolina in the 1970s. It is a structured teaching approach based on the idea that the environment should be adapted to the child with autism, not the child to the environment. It uses no one specific technique, but rather is a program based around the child's functioning level. The child's learning abilities are assessed through the Psycho Educational Profile (PEP) and teaching strategies are designed to improve communication, social and coping skills. Rather than teach a specific skill or behavior, the TEACCH approach aims to provide the child with the skills to understand his or her world and other people's behaviors. For example, some children with autism scream when they are in pain. The TEACCH approach would search for the cause of the screaming and then teach the child how to signal pain through communication skills. There have been criticisms that the TEACCH approach is too structured, that children with autism, particularly high-functioning individuals, become too focused on the charts, organizational aids, and schedules, and that it discourages mainstreaming. Others feel that, in an environment conducive to learning, ultimately the child with autism understands what is expected and how to respond.
Picture Exchange Communication Systems - PECS One of the main areas affected by autism is the ability to communicate. Some children with autism will develop verbal language, while others may never talk. An augmented communication program, such as Picture Exchange Communication Systems (PECS), is helpful to get language started as well as to provide a way of communicating for those children that do not talk. PECS was developed at the Delaware Autistic Program to help children and adults with autism to acquire functional communication skills. It uses ABA-based methods to teach children to exchange a picture for something they want - an item or activity. The advantage to PECS is that it is clear, intentional and initiated by the child. The child hands you a picture, and his or her request is immediately understood. It also makes it easy for the child with autism to communicate with anyone - all they have to do is accept the picture. Floor Time An educational model developed by child psychiatrist Stanley Greenspan, Floor Time is much like play therapy in that it builds an increasing larger circle of interaction between a child and an adult in a developmentally-based sequence. Greenspan has described six stages of emotional development that children meet to develop a foundation for more advanced learning - a developmental ladder that must be climbed one rung at a time. Children with autism may have trouble with this developmental ladder for a number of reasons, such as over-and under-reacting to senses, difficulty processing information, or difficulty in getting their body to do what they want. Through the use of Floor Time, parents and educators can help the child move up the developmental ladder by following the child's lead and building on what the child does to encourage more interactions. Floor Time does not treat the child with autism in separate pieces for speech development or motor development but rather addresses the emotional development, in contrast to other approaches which tend to focus on cognitive development. It is frequently used for a child's daily playtime in conjunction with other methods such as ABA. Social Stories Social Stories were developed in 1991 by Carol Gray as a tool for teaching social skills to children with autism. They address "Theory of Mind" deficits, that is, the ability to understand or recognize feelings, points of view or plans of others. Through a story developed about a particular situation or event, the child is provided with as much information as possible to help him or her understand the expected or appropriate response. The stories typically have three sentence types: descriptive sentences addressing the where, who, what and why of the situation; perspective sentences that provide some understanding of the thoughts and emotions of others; and directive sentences that suggest a response. The stories can be written by anyone, are specific to the child's needs, and are written in the first person, present tense. They frequently incorporate the use of pictures, photographs or music. Before developing and using social stories, it is important to identify how the child interacts socially and to determine what situations are difficult and under what circumstances. Situations that are frightening, produce tantrums or crying, or make a child withdraw or want to escape are all appropriate for social stories. However, it is important to address the child's misunderstanding of the situation. A child who cries when his/her teacher leaves the room may be doing so because he/she is frightened or frustrated. A story about crying won't address the reason for the behavior. Rather a story about what scares the child and how he can deal with those feelings will be more effective. Sensory Integration Children with autism frequently have sensory difficulties. They may be hypo- or hyper-reactive or lack the ability to integrate the senses. Sensory integration therapy, usually done by occupational, physical or speech therapists, focuses on desensitizing the child and helping him or her reorganize sensory information. For example, if a child has difficulties with the sense of touch, therapy might include handling a variety of materials with different textures. Auditory integration therapy reduces over-sensitivity to sound. It may involve having the child listen to a variety of different sound frequencies coordinated to the level of impairment.
Temple Grandin, Ph.D., who herself has autism, developed a "squeeze machine" to help her learn to tolerate touching through regulated deep pressure stimulation. Before proceeding with any sensory integration therapy, it is important that the therapist observe the child and have a clear understanding of his/her sensitivities. Facilitated Communication Facilitated communication (FC) was developed in the 1970s in Australia by an aide who was trying to help a patient with cerebral palsy to communicate. It is based on the idea that the person is unable to communicate because of a movement disorder, not because of a lack of communication skills. FC involves a facilitator who, by supporting an individual's hand or arm, helps the person communicate through the use of a computer or typewriter. It has not been scientifically validated; critics claim it is actually the ideas or thoughts of the facilitator that are being communicated. FC is very controversial and organizations such as the American Association of Mental Retardation, and the American Academy of Child & Adolescent Psychiatry have adopted formal positions opposing the acceptance of FC.
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