This section of the Handbook reviews the autism behavioral treatment literature across the life span from infancy to adulthood, and across the many types of interventions that can be helpful to persons with autism spectrum disorder (ASD) and their families at various times in their lives. High-quality intervention approaches exist for all the core features of ASD: communication, social skills, management of stereotypic behaviors, and other problem behaviors like aggression and self-injurious behavior. They also exist for many different phases of life: school, work, recreation, personal independence, and building social networks. Finally, different types of intervention are needed across the life span, since ASD is a lifetime disorder, but the main targets change from developing social communication skills in infants and toddlers to fostering participation in school environments, to supporting college and university students with ASD, and on into supports for competitive employment and independent living for adults with ASD.
It is gratifying to see the increasing rigor with which intervention studies for ASD are being conducted. This section contains several meta-analyses, and the emphasis on interventions with strong empirical support and strong delivery procedures involving treatment manuals and fidelity measures (see Chapter 31 by Bottema-Beutel and colleagues) demonstrates that autism intervention science has truly come of age. The section begins with chapters addressing core issues in early childhood, including the newly developed studies of (largely parent-implemented) interventions for infants and toddlers (Chapter 29 by Rogers and Vismara); descriptions of a number of comprehensive treatment models for preschoolers (Chapter 30 by Odom and colleagues and Chapter 42 by Reichow and Barton); a chapter specifically focused on supporting social-communication development in early childhood (Chapter 31 by Bottema-Beutel et al.); and the use of augmentative and alternative communication systems, which build on visual strengths and address the needs of the 14% to 25% of children and adults with ASD for whom verbal communication is not successfully supporting their communication needs. Research has increased significantly in this area, and the explosion of new technologies has added new energy to this area of intervention science. Chapter 40, by Fiske and colleagues, reminds us that ASD is a family event, and that the repercussions of ASD take their toll on parents, siblings, and grandparents, who themselves play critical roles as teachers, advocates, friends, and companions of children and adults with ASD. The stress of ASD symptoms and the stress of lack of appropriate resources can undermine family energy and effort needed to support all members of the family, and family supports need to be provided, not only during the individualized family service plan (IFSP) years, but at times throughout the life of a person with ASD. Developmental challenges and crises arise for people with ASD at various points across a lifetime, and these also create family challenges and crises that may benefit from supports.
People with ASD often experience social isolation and lack of access to many environments due to aggressive, destructive, repetitive, stereotypic, or other types of socially inappropriate behavior. The next three chapters each address intervention approaches and strategies that allow people with ASD to find more appropriate and more successful strategies for reaching their own goals so that they can participate in more environments and more interactions with others. In Chapter 33, O'Neill and colleagues provide a current review of treatments for challenging behaviors, highlighting the major contribution of positive behavior supports, functional behavior assessment, and use of antecedent strategies, and the concomitant reduction in strategies emphasizing negative consequences for challenging behavior. The next two chapters, Chapter 34 by Simmons and others, on academic success in the mainstream, and Chapter 35 by Martins and colleagues, focused on supporting students in inclusive education settings, provide detailed and well-tested strategies for addressing the challenges that autism presents to students in school: attention, planning and organization, impulse control, social knowledge and social skills, communication, and access to the “hidden curriculum.” Chapter 36, by Potvin and colleagues, on recreational engagement, is a critical addition to this set of chapters focused on interventions for older children and youth, and it highlights an area critical for adulthood functioning that is most easily developed in childhood and the teen years but is often overlooked, to the detriment of both physical and mental health for people with ASD. Chapter 37, by Bellini and colleagues, presents the research on social skills interventions for school-aged children and so fits well with this group of school-based interventions.
The final set of chapters focuses on older teens and adults with ASD. Two strong chapters, Chapter 38 by Gerhardt and colleagues, on employment services, and Chapter 39 by Wenzel and Brown, on supporting college students with ASD, address the treacherous transition from high school and Individuals with Disabilities Education Act (IDEA) services into adulthood. Both chapters point out the societal lack of commitments and supports for persons with ASD who are no longer supported by individualized education programs (IEPs). Together they provide a rich menu of strategies for supporting young adults in their transition from high school into adult life and work. This theme is carried further in Chapter 41, by Loomis, who discusses the twin goals of independence and interdependence for all adults, including those with ASD. Loomis defines successful adult life in terms of self-management, social support networks, satisfying recreational activities with others and alone, and satisfying and remunerative work. In doing so, and in reminding us all that learning independence and self-management begins in childhood and needs to occur for children with ASD as well as all other children, this chapter ties together all that has come before.
In closing, autism treatment approaches have been described in the literature for the past 50 years, but the scientific maturation of intervention science in ASD is a relatively recent phenomenon. A demonstration of this is seen in the wealth of efficacy studies and the dearth of community-based effectiveness studies in this section. High-quality intervention science in ASD currently remains close to research university settings. This is no doubt due to the time needed to develop a new intervention and take it through the steps needed to demonstrate its effectiveness in community settings. These steps involve developing and piloting it, examining initial efficacy in several single-subject studies, continuing into randomized controlled trials and then into independent replication studies, and then finally shifting to an implementation science framework with well-controlled effectiveness studies in multiple community settings. This time span can currently take 30 to 40 years to complete, and this must be speeded up in order to better serve children and adults with ASD who are here now and in need. We hope that the current priorities involving treatment science set by the National Institutes of Science, Autism Speaks, and other funding groups can allow this process to speed up and support researchers to move their work through these phases as quickly as possible.
