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Clinical Practice Guideline - Table of Contents

CHAPTER IV
INTERVENTION METHODS FOR YOUNG CHILDREN WITH AUTISM

  • Chapter IV - General References

     

    CHAPTER IV

    INTERVENTION METHODS FOR YOUNG CHILDREN WITH AUTISM

    There is substantial evidence that children with a variety of developmental delays and disorders have a greater chance for successful outcomes if interventions are started at an early age (Guralnick, 1998). Hope for potentially successful outcomes has led, in part, to the increased emphasis on programs for "early intervention" over the past decade. According to many experts, intervention at early stages in the child's development may have a greater chance for success for children with autism.

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    Description of the Common Elements of Effective Intervention Programs

    Over the last 25 years, a small number of programs have worked intensively on researching interventions for young children with autism and their families. These programs have been open in publishing and sharing information about the characteristics of children served, the methodologies used, and the child and family outcomes. Although the programs vary in their philosophical approach and strategies, they include several common elements.

    Eight model early intervention programs for children with autism were recently reviewed by Dawson and Osterling (1997). Clinical outcome data from some of these programs has been published in studies that met criteria for use as evidence in this guideline. Information from these studies provides a useful framework for understanding the common elements of effective intervention programs.

    Common Elements of Effective Interventions 

    Dawson and Osterling (1997) described the following six elements which seemed to be common to effective intervention programs.

    1. Curriculum content. The curricula of the programs emphasize five basic skill domains, including the following abilities: 1) to attend to elements of the environment that are essential for learning, especially to social stimuli; 2) to imitate others; 3) to comprehend and use language; 4) to play appropriately with toys; and 5) to interact socially with others.

    2. Highly supportive teaching environments and generalization strategies. The programs first try to establish core skills in highly structured environments and then work to generalize these skills to more complex, natural environments.

    3. Predictability and routine. Since the behavior of children with autism is easily disrupted by changes in environment and routine, the programs adopt strategies to assist the child with transitions from one activity to another.

    4. Functional approach to problem behaviors. Since young children with autism often show problem behaviors, the programs first try to prevent the development of these behaviors by structuring the environment. If problem behaviors persist, the programs use a functional approach that involves the following steps: 1) recording the behavior; 2) developing a hypothesis about the function that behavior serves for the child; 3) changing the environment to support appropriate behavior which allows the child to cope effectively with the situation; and 4) teaching appropriate behaviors to replace problem behaviors.

    5. Plans for transition from preschool classroom. The programs teach "survival" skills that children will need later on in order to function independently in preschool or school classrooms.

    6. Family involvement. The programs include parents as a critical component in the intervention for young children with autism. Family involvement is an important factor for success of a program because parents can provide unique insight into creating an intervention plan and can provide additional hours of intervention. Including parents in the intervention can also help children achieve greater maintenance and generalization of skills and can help reduce parents' stress levels.

    The common elements of effective programs were derived from a review by Dawson and Osterling of the following programs:

    1. Douglass Developmental Disabilities Center
    2. Health Sciences Center, University of Colorado
    3. Learning Experiences - An Alternative Program for Preschoolers and Parents (LEAP)
    4. May Institute
    5. Princeton Child Development Institute
    6. Treatment and Education of Autistic and Communication-Handicapped Children (TEACCH)
    7. Walden Preschool
    8. University of California at Los Angeles (UCLA) Young Autism Program.

    Linking Interventions to Assessment of the Child

    Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

    Recommendations

    Linking early identification and diagnosis with early intervention

    1. It is important to identify children with autism and begin appropriate interventions as soon as possible since such early intervention may help speed the child's overall development, reduce inappropriate behaviors, and lead to better long-term functional outcomes. [D1]

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    1. It is recommended that appropriate interventions be provided as soon as possible after a diagnosis of autism has been made. [D1]

    2. If a child has identified developmental delays and autism is suspected but not confirmed, it is still important to initiate appropriate early intervention services to address identified developmental delays as soon as possible. [D2]

    3. Although early intervention is recommended, it is important for parents to understand that children who receive intervention at a later age can still benefit from intervention. [D1]

    4. When making decisions about interventions for a child with autism, it is recommended that parents seek guidance from qualified professionals with experience in treating children with autism. [D2]

    Individualizing interventions based on information from the assessment

    1. It is important to recognize that children with autism differ in terms of their strengths and needs, as well as their responses to specific intervention methods or techniques. Furthermore, children have different family situations. [D1]

    2. It is recommended that the use of any intervention for a child with autism be based upon an assessment of the specific strengths and needs of the child and family. [D1]

    3. It is recommended that target behaviors for each individual child be clearly identified and defined with developmentally appropriate measurable criteria for mastery. [A]

    Ongoing monitoring of the child's progress and modification of interventions

    1. It is recommended that any intervention be tied to ongoing monitoring of the child's progress by parents and professionals. [A]

    1. If ongoing assessment of the child's progress shows an intervention has not been effective after an adequate trial period, it is recommended that the intervention or specific aspects of its application be changed. [A]

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    Periodic in-depth reassessment

    1. In making a decision either to start or change a specific intervention for a child with autism, it is important that parents and professionals consider:

      • the best available scientific evidence about the effectiveness of the intervention and alternatives

      • learning rates of children with autism

      • potential risks or harms associated with the intervention [D1]

    1. It is recommended that parents and professionals consider modification of an intervention when:

      • the child has progressed and target objectives have been achieved

      • progress is not observed after an appropriate trial period

      • the child has shown some progress but target objectives have not been achieved after an appropriate trial period

      • there is an unexpected change in a child's behavior or health status

      • there is a change in the intervention setting (such as moving from the home to a preschool setting)

      • there is a change in family priorities [D1]

    1. In addition to ongoing monitoring, it is recommended that periodic in-depth re-assessment of the child's progress and developmental status be done at least once every six to twelve months. [D2]

    2. As part of the periodic in-depth re-assessment of the child, it is important to:

      • include appropriate standardized testing to help assess the child's progress using that intervention method
      • assess the child's individual progress and functional level and compare these to the child's age-expected levels of development and functioning [D2]

    General Considerations in Implementing Interventions

    Recommendations

    Need for scientific validation of efficacy and safety of interventions

    1. It is recommended that in selecting interventions for children with autism, scientific evidence for efficacy is an important consideration. [D2]

    2. It is recommended that scientifically valid research continue to be done on the effectiveness of interventions for children with autism. [D2]

    3. In carrying out further research to determine which interventions are effective, it is recommended that adequate precautions be taken for child safety. [D2]

    Collaboration and coordination

    1. It is important that techniques and approaches be coordinated, integrated, and collaborative across all individuals working with the child and family. [D2]

    2. When a team approach is used, it is important that team members communicate with each other about the child's progress. [D2]

    3. It is important that there be appropriate supervision of paraprofessional staff and coordination of efforts to accomplish agreed-upon intervention goals. [A]

    Planning a comprehensive intervention

    1. When planning a comprehensive intervention program for an individual child with autism, it is recommended that if multiple intervention components are used, then careful consideration be given to integrating the intervention approaches and/or components to make sure they are compatible and complementary. [D2]

    Addressing co-existing developmental and health problems

    1. As part of the intervention plan, it is important to address any of the child's other developmental and/or health problems that may [D2]

    Use of physically intrusive approaches and physical aversives

    1. The use of physical aversives (such as hitting, spanking, slapping, or pinching) is not recommended as a part of any intervention program. There is evidence that interventions for children with autism can be successful without the use of physical aversives. [A]

    2. It is recommended that any physically intrusive procedure used as a component of an intervention (holding, restraining, or physical redirection) be used only after less intrusive measures have been attempted. If used, it is important that there be extremely careful justification, informed consent of the parents, and extensive training and regular monitoring of staff carrying out the procedure.[D1]

    3. Physical prompts or cues (a tap on the arm, a hand clap, or a verbal command) can be an important component of an intervention approach. It is, however, important to be aware that the difference between a "physical prompt" and a "physically intrusive procedure" is defined in part by the child's experience of and reaction to the procedure. The degree to which physical and sensory stimuli (noise or touch) may be physically intrusive varies from one child to another.[D1]

    Role of The Parents and Family in Interventions

    Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

    Recommendations

    Role of the family in assessment and intervention processes

    1. It is important that parents be involved as active participants in all aspects of the child's ongoing assessment and intervention process to the extent of their interests, resources, and abilities. [D2]

    2. Parental involvement is important to ensure that the family's desired outcomes for the intervention, as well as the family's values and priorities, are considered when developing the intervention plan. [D2]

    3. It is recommended that professionals share with parents the scientific evidence about effectiveness of the intervention methods being proposed or used, as well as the advantages and disadvantages of the proposed methods. [D2]

    4. It is important for professionals working with the child to understand and respect the family's values, priorities, and parenting philosophies. [D2]

    Considering the cultural context of the family

    1. A child's life is embedded within a cultural context. It is essential to consider and respect the family's culture when providing interventions for children with autism. [D2]

    2. If English is not the primary language of the family, it is important for professionals to look for ways to communicate effectively with the family and the child, including use of health care professionals, early intervention professionals, or translators who speak the family's language. [D2]

    Common Elements of Effective Intervention Programs

    Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

    Recommendations

    Selecting an intervention program

    1. When selecting a comprehensive intervention program for a young child with autism, it is recommended that parents and professionals consider the following aspects of the program:

      • content and emphasis of the program's curriculum

      • strategies for using a functional approach for problem behaviors

      • strategies for providing a highly structured and supportive teaching environment, with a high degree of predictability and routine

      • strategies for taking skills learned in more structured settings and generalizing them to more complex natural environments

      • strategies for transitions from one activity to another during the day

      • long-term strategies for transition between intervention settings

      • opportunities for family involvement [A]

    Recommendations about program curriculum

    1. It is recommended that comprehensive intervention programs have a curriculum content specifically designed for children with autism. It is important that the program curriculum focus on developing increased attention to social stimuli, imitation skills, communication and language, symbolic play, and social relationships. [A]

    2. It is recommended that the curriculum of an intervention program for a child with autism be individualized based on that child's specific strengths and needs. [A]

    Recommended elements for programs

    1. It is recommended that comprehensive intervention programs for young children with autism include the following elements:

      • a functional approach to dealing with problem behavior

      • a highly structured and supportive teaching environment

      • a high degree of predictability and routine

      • strategies for generalization of skills to less restrictive settings

      • strategies for transition between daily activities

      • long-term strategies for transitions between intervention settings

      • opportunities for family involvement [A]

    1. Because children with autism have a need for predictability and routine, it is recommended that comprehensive intervention programs provide strategies for the children to deal with transitions such as changes in schedule, activity, or routine during the day. To facilitate transition in activities, cue cards or other visual aids may be used. [A]

    Need for a continuum of intervention strategies

    1. A continuum of intervention strategies is important as the child progresses in independence. As the child's skills progress, it is useful for the focus of the intervention to shift from an emphasis on one-to-one therapy to include interactions in larger groups. It is also useful for the intervention setting to gradually move from highly structured and restricted environments to more natural environments such as preschools with typical peers. [A]

    2. It is recommended that comprehensive intervention programs use a functional approach to problem behaviors. This involves carefully recording the child's problem behavior, attempting to understand why it occurs, changing the environment to encourage appropriate behavior, and teaching appropriate behavior to replace the problem behavior. [A]

    3. It is recommended that comprehensive intervention programs prepare children for transition to more general settings (such as preschool) by teaching them to function as independently as possible. [A]

    4. It is recommended that comprehensive intervention programs provide opportunities for parent involvement including participation in intervention planning, parent training to assist in the intervention, and regular consultation with professionals regarding the progress of their child. [A]

    Parent Intervention Guide:
    Questions to Ask Providers

    The following are questions that may be helpful to parents, caregivers, or other individuals when interviewing potential intervention providers. These questions were developed from the guideline recommendations on interventions.

    1. What kinds of intervention, therapy, and services do you provide?

    2. Do you have a particular philosophy on working with children with autism/PDD?

    3. How many hours per week do these services require, and how much of this is one-on-one time with the child?

    4. Please describe a typical day or session.

    5. What experience do the teachers and/or therapists have in working with children with autism?

    6. What experience does the person who supervises the program have? How closely does the program supervisor work with the therapists, teachers, and parents?

    7. What kinds of ongoing training do your full- and part-time staffs participate in?

    8. Are parents involved with planning as part of the intervention team?

    9. Do you provide a parent training program?

    10. How much and what kinds of involvement are expected of parents and family members?

    11. Are parents welcome to participate in or observe therapy and/or group sessions?

    12. What techniques do you use to manage difficult behaviors?

    13. Do you ever use physical aversives or any physically intrusive procedures? If yes, please describe them.

    14. Please describe your program for communication and language development. Do you use a picture communication system, sign language, other kinds of communication systems, or all of these?

    15. Are there opportunities for integration with typical and/or higher functioning children?

    16. How do you evaluate the child's progress, and how often?

    17. How do you keep parents informed of the child's progress?

    Behavioral and Educational Approaches

     


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