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
- Head-banging.
Children with autism may also engage in self-mutilation, such as eye-gouging or biting their arms; they 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 a child with autism may resort to screaming (because of an inability to use language to communicate his/her needs).
Many treatment approaches have been developed to address the range of social, language, sensory, and behavioral difficulties.
These include Discrete Trial Training (discrete trials), as part of:
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.
Treatment & Education of Autistic and Related Communication of Handicapped Children (TEACH)
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. TEACCH uses 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 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 mainstream behavior (meaning that they may only respond to specific stimuli as taught in their curriculum and not everyday situations). 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.
Pivotal Response Treatment
Regarded as one of the top state-of-the-art treatments for autism in the United States*, Pivotal Response Treatment (PRT) is a naturalistic intervention model producing positive changes in critical behaviors, leading to generalized improvement in communication, social, and behavioral areas. Rather than target individual behaviors one at a time, PRT targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations. By targeting these critical areas, PRT results in widespread, collateral improvements in other social, communicative, and behavioral areas.
The underlying motivational strategies of PRT are incorporated throughout intervention as often as possible, and they include child choice, task variation, interspersing maintenance tasks, rewarding attempts, and the use of direct and natural reinforcers. The child plays a crucial role in determining the activities and objects that will be used in the PRT exchange. For example, intentful attempts at functional communication are rewarded with a natural reinforcer (e.g., if a child attempts a request for a stuffed animal, the child receives the animal, not a piece of candy or other unrelated reinforcer). Pivotal Response Treatment is used to teach language, decrease disruptive/self-stimulatory behaviors, and increase social, communication, and academic skills.
* National Research Council of the National Academy of Sciences, 2001
Floor Time
An educational model developed by child psychiatrist Stanley Greenspan, Floor Time is much like play therapy in that it builds an increasingly 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 that tend to focus on cognitive development. It is frequently used for a child's daily playtime.
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, which can be written by anyone, are specific to the child's needs, and are written in the first person, and 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.
Temple Grandin, Ph.D., who herself has autism, developed a "squeeze machine" to help her learn to tolerate touching through regulated deep pressure stimulation.
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.
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.
Faciliated 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.
Complementary Approaches
While early educational intervention is key to improving the lives of individuals with autism, some parents and professionals believe that other treatment approaches may play an important role in improving communications skills and reducing behavioral symptoms associated with autism. These complementary therapies may include music, art or animal therapy and may be done on an individual basis or integrated into an educational program. All of them can help by increasing communication skills, developing social interaction, and providing a sense of accomplishment. They can provide a non-threatening way for a child with autism to develop a positive relationship with a therapist in a safe environment.
Art and music are particularly useful in sensory integration, providing tactile, visual and auditory stimulation. Music therapy is good for speech development and language comprehension. Songs can be used to teach language and increase the ability to put words together. Art therapy can provide a nonverbal, symbolic way for the child with autism to express him or herself.
Animal therapy may include horseback riding or swimming with dolphins. Therapeutic riding programs provide both physical and emotional benefits, improving coordination and motor development, while creating a sense of well-being and increasing self-confidence. Dolphin therapy was first used in the 1970s by psychologist David Nathanson. He believed that interactions with dolphins would increase a child's attention, enhancing cognitive processes. In a number of studies, he found that children with disabilities learned faster and retained information longer when they were with dolphins, compared to children who learned in a classroom setting.
As with any therapy or treatment approach, it is important to gather information about the treatment and make an informed decision. Keep in mind however, as with most complementary approaches, there will be little scientific research that has been conducted to support the particular therapy.
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