Autism

Educational and Therapeutic Approaches

Efrosini Kalyva

• Publisher: SAGE Publications Ltd
• Year: 2011
• ISBN:
  9781446292341
• Edition: 1
• Topic: Education
• Subtopic: Learning Disabilities

There are a number of different approaches and therapies available for children, young people and adults on the autistic spectrum, and the amount of information available on each one can be daunting for professionals and parents alike. This book offers concise and clear explanations of a variety of proposed interventions and their effectiveness, and helps the reader to decide on the most appropriate treatment for each individual.

Efrosini Kalyva writes accessibly about recent scientific evidence and the latest research, and allows you to consider the pros and cons of each approach. She focuses on the following areas:

-cognitive-behavioural approaches

-developing social interaction

-alternative communication strategies

-developing play

-sensory-motor approaches

-psychotherapeutic approaches

-biochemical approaches

This much-needed guide for practitioners and student teachers will also appeal to interested parents, and to anyone looking for a comparative examination of the variety of treatments on offer.

1

Cognitive-Behavioural Approaches

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Chapter overview

I begin this chapter with a critical review of the approaches that have proven most effective for the treatment of ASD according to relevant published studies. I refer in particular to applied behaviour analysis (ABA) and TEACCH, which have been used successfully with individuals with ASD for many years in a variety of countries and cultural contexts. Applied behaviour analysis targets primarily young children with ASD, recognising the vital importance of early intervention that can bring about noticeable changes in the symptoms, while TEACCH provides a ‘cradle to grave’ service. Both methods that I will present and analyse in more detail have advantages and disadvantages that should be taken into consideration when assessing their effectiveness. You should also bear in mind that there is no individual therapeutic or educational approach that has been proven to address all the characteristic behaviours of all children with ASD.

At the end of this chapter, I refer to some approaches that are based mainly on behaviour modification techniques and have been applied to a lesser extent. Cognitive-behavioural therapy (CBT) is designed mainly for high-functioning children with ASD who can communicate adequately. The Denver Health Sciences Programme, the DIR/Floortime method, the LEAP programme and the Miller method are behaviourally oriented programmes that were designed to help children with ASD and their families. Despite the fact that these methods differ in the way that they are implemented, a common underlying feature is the instruction of learned behaviours that leads to mastering a specific skill.

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Applied behaviour analysis

Applied behaviour analysis is a behavioural approach that has been used for more than 40 years with satisfactory success rates (Foxx, 2008; Heflin and Alberto, 2001). It is based on fundamental principals of operant conditioning (the relation that exists between the stimulus and the response), as well as other principles of behavioural instruction that aim at changing a problematic or unwanted behaviour (Cooper et al., 1989), which should be improved or stopped by the end of the intervention (Baer et al., 1968; Sulzer-Azaroff and Mayer, 1991). Target behaviours for children with ASD include social skills, communication, academic performance and adaptation skills, such as gross and fine motor skills, preparation and consumption of food, use of toilet, getting dressed, personal hygiene, the ability to find their way around in the house and the community, skills that are needed to find a job and understand concepts such as time and money (Maurice et al., 1996).

Applied behaviour analysis is based on the observation that ASD is a syndrome of behavioural deficits and excessive reactions that have a neurological basis, but can be significantly improved within controlled frameworks (Lovaas et al., 1989). More specifically, ABA focuses on the systematic instruction of small and measurable behavioural units. It is essentially an objective science that is based on the reliable measurement and the objective evaluation of a behaviour that you observe and you wish to modify. In order to reliably measure the change in behaviour, you must first understand and define it accurately (Powers, 1992). Certain behaviours, such as eye contact, can be easily defined because they are discernible, they have measurable duration and they can be easily perceived. However, there are many vague, multidimensional and complex behaviours, such as anger, depression and aggression, that you may wish to modify or extinguish. In order to record directly the frequency, the duration and other measurable variables of a behaviour, you must first define it using observable and quantifiable terms (Sulzer-Azaroff and Mayer, 1991). For example, aggressive behaviour could be defined as: ‘attempts, episodes, or instances of biting, scratching, pinching or hair pulling’. The ‘initiation of social interaction with peers’ could be defined as: ‘eye contact with the peer and use of an appropriate greeting gesture’. Once you succeed in defining these behaviours in an objectively acceptable way, you can then observe them and conclude whether they improved after the implementation of a behavioural intervention, and present convincing evidence to support your claims (Baer et al., 1987). The behaviours that you wish to alter are usually assessed in the contexts where they are observed – usually the house, the school and the wider community. A thorough evaluation of the effectiveness of the intervention is accomplished by (Sulzer-Azaroff and Mayer, 1991):

• choosing a behaviour that you wish to improve (for example, lack of eye contact);
• identifying and defining the desirable targets (for example, to increase the frequency and duration of eye contact);
• defining a way to measure the behaviours that you study (for example, record how often the child looks at people in his environment and time the duration of this eye contact);
• evaluating the current level of performance (for example, to have a reference point; if you want to be able to conclude whether the intervention was effective, you must know the duration and the frequency of eye contact before the beginning of the intervention);
• designing and implementing the appropriate intervention to change the problematic behaviour by teaching new alternative skills (for example, to reward the child every time that he looks in your eyes by giving him something he wants);
• assessing the target behaviours continuously in order to determine the intervention’s effectiveness (for example, to collect measurements, at regular intervals, of the frequency and the duration of eye contact in order to estimate whether the desirable changes have taken place);
• evaluating constantly the effectiveness of the intervention and the appropriate modifications to maintain and/or to increase the effectiveness and the efficacy of the intervention (for example, if you have not succeeded in increasing the frequency and the duration of eye contact, then you must attempt to identify the mistakes that you made and correct them). When you meet your targets, you must then make sure that the change is permanent and can be generalised to other settings and to other individuals. To return to the example of eye contact, you must be certain that it remains increased after a period of 3 to 5 months or that it has been incorporated into the repertoire of the child’s behaviours. You should also examine whether the child can maintain eye contact with different people in different contexts, that is, to generalise the skill that he has mastered (Green, 1996b). If the child has not achieved this, then the intervention is not complete and you need to work further on the concept of generalisation.

You can use ABA to address a wide range of skills and behaviours that impede and inhibit the progress of children with ASD, such as aggressive behaviours, which are characterised by lack of understanding of the child’s own agency and the effects on others (Sigafoos and Saggers, 1995), self-help skills (Matson et al., 1990), self-stimulation (Epstein et al., 1985; Lovaas et al., 1987), play skills (Thorp et al., 1995), communication skills (Bryen and Joyce, 1985; Koegel et al., 1988) and academic skills (Kamps et al., 1994). It is worth emphasising that ABA aims not just to reduce or stop undesirable behaviour, but also to encourage the development of appropriate and desirable behaviour.

Before presenting ABA, I refer to discrete trial learning that constitutes one of its fundamental teaching methodologies and aims at controlling the wealth of information and the interaction opportunities that are usually presented to children with ASD. Since a child with ASD might have difficulty reacting to many stimuli simultaneously, he must learn to handle effectively a small amount of stimuli every time (Koegel et al., 1982a). This method helps children with ASD to control the learning process, so that they can more easily master the skills that they need to function effectively. They initially achieve the first step and then they move to the next, until they reach the final target.

Every teaching unit includes five basic stages that remain stable regardless of the skill that constitutes the final target:

1. The teacher or the therapist presents a short and concise instruction or question (stimulus) (for example, sit on the chair).
2. The instruction is followed by a prompt to promote the correct response (for example, the chair is there, go and sit on the chair).
3. The child reacts correctly or incorrectly (response) (for example, the child does not move, or sits on the floor or sits on the chair).
4. The teacher or the therapist responds appropriately to the child’s behaviour. She reinforces and rewards the correct responses with something that the child likes – something edible, a toy, a hug or praise – while she ignores or corrects inappropriate responses (for example, gives some chocolate to the child who sits on the chair or physically guides the child who does not respond to sit on the chair).
5. The teacher or the therapist records the behaviours that she observes in order to create a profile of the child’s abilities. This profile will help her decide the skills that she will teach the child and organise them according to the level of difficulty (for example, a child with problems in fine motor skills must first learn to hold the pencil appropriately and then manage to write or draw).

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Question for discussion

Think of a behaviour that you would like to teach to a child with ASD. How would you use these stages to accomplish your goal? What would you use as reinforcers/rewards? What problems could you encounter and how would you handle them?

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Newsom and Rincover (1989) explained that discrete trial learning can be used to teach basic skills – such as focusing and maintaining attention – and many more elaborate verbal and social skills that are important for independent function. The therapy starts with two primary aims: (a) the instruction of learning readiness skills, such as the ability to sit on a chair and pay attention to what is going on in the environment, and (b) the decrease of behaviours that inhibit learning, such as lack of compliance, temper tantrums and aggression. Discrete trial learning is also the basis for practising and achieving social interaction skills.

As soon as the child learns to sit quietly and pay attention, he can be taught more complex skills, such as social behaviours and communication. Social skills training starts with eye contact (which should be meaningful) and continues with imitation, learning through observation, the expression of affection, and social play. You usually teach social skills by helping the child initially to understand the procedure of naming objects (for example, to realise that the round thing that bounces off the floor is called ball), to name objects on his own (for example, to show the ball and say ‘ball’) or to use complete sentences (for example, ‘this is a red ball’), and, finally, to look for spontaneous communication (for example, to approach his mother and say, ‘Mum, can you give me the ball?’, but without asking him previously if he wants to play with the ball). If the child is non-verbal, then he can use alternative forms of communication to enhance these social skills, as will be discussed in Chapter 3. As soon as the child masters these social skills, he learns to express himself in order to get what he wants, that is, to be rewarded for exhibiting the appropriate behaviour. Then the child has to generalise the ability to communicate with other people apart from his mother and in other settings apart from the house (McGee et al., 1985). Since children with ASD do not usually learn spontaneously from the environment, you must teach them almost everything that they need to do (Green, 1996b), even if you believe that it is self-evident.

Discrete trial training in combination with other principles and methods that make up ABA have been shown to be extremely valuable in designing instruction in the classroom; in defining the motives that you must provide to children with ASD in the classroom; in choosing classroom behaviour management strategies; and in devising assessment procedures and techniques for the child (Martens et al., 1999). In order to achieve the best possible outcome, you have to be particularly sensitive to the individual differences of children with ASD. You can deal successfully with each child’s individual needs by observing him and collecting data about his behaviour in an attempt to locate the factors that you must take into account in order to design an effective intervention. The targets that you set within the context of ABA programmes are the following (Dunlap et al., 2001):

1. You locate the objects or the situations that could motivate a child with ASD to express and to maintain a positive behaviour by acting as rewards or reinforcers (for example, listening to music, walking to the playground). To do this, you have to observe the child and collect supplementary information from his parents or teachers, and initially use primary and direct rewards, which are more powerful (for example, food or toys), while later you move on to secondary and indirect rewards, which delay gratification and are more socially oriented (for example, verbal praise). The ultimate goal is to start withdrawing the rewards gradually, so that the child can experience pleasure from exhibiting the desired behaviour and not from receiving a reward. At the same time you could identify and remove any objects or situations that cause stress or fear to the child and prevent him from functioning normally or that make him feel insecure.
2. You define the child’s weaknesses and deficits and try to create the appropriate tasks that will help him to fill any cognitive gaps and keep up with his peers. If you want to get a full picture of the child’s range of abilities you have to test him thoroughly using all the appropriate standardised tests, and bear in mind that he might perform adequately in some tasks and face problems in others.
3. You teach the child to generalise the skills and abilities that he has mastered to other settings in order to overcome his limitations (for example, to be able to read a text both at school and at home or to cooperate both with his parents and with his teacher).
4. You show the child the techniques and strategies that he needs in order to control his behaviour without needing the intervention of an adult to bring him back to order (for example, when he feels that he misses the meaning of the text that he reads, then he can start underlining the central ideas; when he gets angry at the child who sits next to him, he should tell the child to be quiet and not hit him). If he manages to gain self-control, he will be able to function more effectively in the classroom, since he will exhibit less disruptive behaviour and will facilitate the teacher’s role. It is important to understand that in order to include a child with ASD in a mainstream setting, he has to develop not only academic but also social skills.

Therapists who practise ABA have, over time, reviewed some of the basic principles that they have adopted and that have proven to be either dysfunctional or ineffective. So, they have reached a point where they have introduced new practices to ABA that include positive behavioural support, functional assessment and training in functional communication.

Positive behavioural support aims to enable children to acquire behaviours that will help them adjust and become socially acceptable. In order to achieve this, they have to overcome the behaviours that are destructive, dysfunctional and stigmatising (Koegel et al., 1996). A primary ...