Behavioral and Communication Approaches

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.

Treatment and Education

Overview
 
Discovering that your child has autism can be an overwhelming experience. For some, the diagnosis may come as a complete surprise; others may have suspected autism and tried for months or years to get an accurate diagnosis. In either case, you probably have many questions about how to proceed. A generation ago, many people with autism were placed in institutions. Professionals were less educated about autism than they are today and specific services and supports were largely non-existent. Today the picture is brighter. With appropriate services, training and information, children with autism will grow and can learn, even if at a different developmental rate than others.

While there is no cure for autism, there are treatment and education approaches that may reduce some of the challenges associated with the disability. Intervention may help to lessen disruptive behaviors, and education can teach self-help skills that allow for greater independence. But just as there is no one symptom or behavior that identifies autistic children, there is no single treatment. Children can learn to function within the confines of their disability, but treatment must be tailored to the child's individual behaviors and needs.

Please keep in mind that the descriptions of treatment approaches provided here are for informational purposes only. They are meant to give you an overview of an approach. To find additional resources and books, click here. The Autism Society of America does not endorse any specific treatment or therapy. For more information about the ASA's policy on options, click here.

Treatment and Education Approaches

During your research, you will hear about many different treatments approaches, such as auditory training, discrete trial training, vitamin therapy, anti-yeast therapy, facilitated communication, music therapy, occupational therapy, physical therapy, and sensory integration.

These approaches can generally be broken down into two categories: Treatment and Education. Treatment approaches include:

• dietary and biomedical approaches
• complementary approaches

Some treatment approaches have research studies that support their efficacy; others may not. Some parents will only want to try treatment methods that have undergone research and testing and are generally accepted by the professional community. But keep in mind that scientific studies are often difficult to do since each individual with autism is different.

For others, formal testing might not be a pre-requisite for them to try a treatment with their child. Even for those with "scientific" proof, we recommend that the family or caregiver investigate all options available to determine the appropriateness.

Understanding Your Options

As a parent, it's natural to want to do something immediately. However, it is important not to rush in with changes. Your child may have already learned to cope with his or her current environment and changes can be stressful. You should investigate various treatment approaches and have a plan in place before proceeding.

Treatment approaches have evolved as more is learned about autism. There are therapeutic programs - both conventional and complementary - that focus on replacing dysfunctional behaviors and developing specific skills. Just as there are various treatment approaches, there are multiple educational programs that provide stimulating learning environments. The Individuals with Disabilities Education Act (IDEA) is a federal mandate that guarantees students with disabilities a free, appropriate public education. The education plan for a student with disabilities can include "related services" that may encompass many of the treatments discussed here.

It is important, however, that you gather information concerning various options before making decisions concerning your child's treatment. You will encounter numerous accounts from parents about successes and failures with many of the treatment approaches mentioned. You will also discover that professionals differ in their theories of what they feel is the most successful treatment for autism. It can be frustrating! But, you can learn to sift through them, and make rational, educated decisions on what is appropriate for your child. You live with your child day by day. You know his/her needs, and you will come to know his/her autism. Trust your instincts as you explore various options.

Finding Treatment Programs in Your Area

Once you become familiar with the treatments that are available and appropriate for individuals with autism, you may be concerned about where they can receive these services. Treatments may be obtained through either the medical or educational community, depending on the nature of the treatment. There are a variety of resources you can use to find qualified professionals or service providers in your area. There are several state agencies established to provide this type of information and support, including Protection and Advocacy; Developmental Disabilities Planning Councils; Vocational Rehabilitation Centers; Parent Training Centers; and Educational Resources. You should also try your local ASA chapter for tips on programs and professionals in your area.

Each Child Has Unique Needs and Abilities

Individuals with autism, like everyone, are individuals first and foremost. They have unique strengths and weaknesses. What people with autism have in common is a developmental disability, a disorder of communication, which manifests itself differently in each person. Some individuals with autism may be of average to above average intelligence, while others may be below average.

Academic goals need to be tailored to the individual's intellectual ability and functioning level. Some children may need help in understanding social situations and developing appropriate responses. Others may exhibit aggressive or self-injurious behavior, and need assistance managing their behaviors. No one program will meet the needs of all individuals with the disability, so it is important to find the program or programs that best fit your child's needs. Both treatment approaches and educational programs should be tailored to your child's individual needs, should be flexible and should be re-evaluated on a regular basis.

More Information

Treatment Options	Education
Overview	Overview
	IDEA and Your Child's Rights
Biomedical and Dietary Approaches	Individualized Education Plan (IEP)
Complementary Approaches	Support Agencies

© Copyright 2003, Autism Society of America 

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.