CHAPTER IV (continued)

This section evaluates evidence about efficacy of behavioral and educational intervention approaches for young children with autism. Behavioral and educational interventions have become the predominant approach for treating children and adults with autism (Bregman and Gerdtz, 1997). In recent years several intensive intervention programs for children with autism have been developed utilizing a systematic behavioral approach, often referred to as applied behavioral analysis (ABA) . Many of the current forms of speech and language therapy and many other educational interventions for young children with autism are based upon somewhat similar behavioral principles.

Behavioral and educational intervention programs for young children are reviewed together as part of this because they are based upon common behavioral principles and share common elements. This section of the guideline also evaluates evidence about the effectiveness of training parents to become active participants in behavioral and educational interventions for their child. The panel's recommendations about common elements of effective intervention programs (presented in the beginning of this chapter) were derived in part from information discussed in this section.

Before evaluating specific programs and approaches discussed in this section, it is useful to review some basic behavioral principles and the ways these can be incorporated into behavioral and educational intervention programs for children with autism.

Basic principles of behavioral and educational intervention approaches

Behavioral therapies include specific approaches to help individuals acquire or change behaviors. All behavioral therapies are based upon some common concepts about how humans learn behaviors. Behavioral therapies, which are sometimes also called behavioral modification methods, can be divided into three general approaches: operant conditioning, respondent (Pavlovian) conditioning, and cognitive approaches. In treating children with autism, operant conditioning approaches are typically used.

At the most basic level, operant conditioning involves presenting a stimulus (antecedent) to a child, and then providing a consequence (a "reinforcer" or a "punisher") based on the child's response.

• A reinforcer is anything that, when presented as a consequence of a response, increases the probability or frequency of that response. Examples of possible reinforcers for young children may include verbal praise, or offering the child a desired toy.
• A punisher is a consequence that decreases the probability or frequency of that response. Possible punishers for young children may include verbal disapproval or withholding a desired object or activity. The term "punisher" is a technical term used in behavioral therapy and does not imply the use of physical aversives such as hitting, slapping, spanking, or pinching.

Reinforcers and punishers are different for each child. Part of operant conditioning approaches is to perform a functional assessment of possible reinforcers or punishers to determine which are most effective in shaping a child's behaviors.

While all behavioral therapies have some basic similarities, specific behavioral techniques vary in several ways. Some techniques focus on the antecedent conditions and involve procedures implemented before a target behavior occurs.

Other techniques focus on the consequence of a behavior and involve procedures implemented following a behavior. Still other techniques involve skill development and procedures teaching alternative, more adaptive behaviors. These strategies often consist of building complex behaviors from simple ones through shaping and successive approximations.

Some types of behavioral interventions use discrete trials. In a discrete trial, the therapist presents an antecedent, the child responds, and the therapist presents an appropriate consequence. For example, a therapist would show a child ten pictures and give a reinforcer each time the child named a picture correctly.

Many different specific behavioral and educational techniques have been used as part of interventions for individual children with autism. These techniques are grounded in a vast body of research based on a common set of behavioral and learning principles. Behavioral interventions involve the therapist controlling antecedents and/or consequences to shape the child's responses. Some strategies focus primarily on antecedents, while other strategies focus on the consequences.

As used here, the term "behavioral techniques" refers to specific procedures aimed at teaching new skills and behavior. Intensive behavioral intervention programs use an array of behavioral techniques that change over time as the child progresses and as different skill areas are addressed. Studies of the effectiveness of behavioral techniques tend to focus on short-term changes in the responses of the child, while studies of programs often focus on long-term outcomes for the child or family.

Behavioral and educational approaches for children with autism often include elements of many of these behavioral intervention strategies. As the child's autistic behaviors decrease and level of functioning improves, these programs may also incorporate some elements of other approaches, such as developmental and cognitive approaches.

Specific targets of the interventions are chosen based on the child's individual problems and deficits. Children with autism often exhibit behaviors that are considered maladaptive, and a reduction in these behaviors is often the first intervention target. After behavior problems are controlled, the intervention targets can shift to dealing with other aspects of autism, such as improving communication and social interaction. Goals in an intensive behavioral intervention program will also change as the child improves or when there is a change in the environment.

Variations in behavioral and educational interventions: Naturalistic and directive approaches

Behavioral and educational interventions can vary according to whether they are more directive or more naturalistic in their approach. In directive approaches, the therapist controls all aspects of the intervention. An example of this approach is discrete trial learning. In directive approaches, the therapist structures the environment and specifies the antecedent stimuli and consequences (which may not necessarily flow logically from the child's current activities or interests). In contrast, naturalistic approaches attempt to make the intervention setting similar to the child's usual environment and also attempt to use antecedent stimuli and reinforcers that are related to the child's usual environment and everyday activities. In practice, few therapies are either totally directive or totally naturalistic. Instead, most interventions fall somewhere on a continuum between these two approaches, incorporating some directive and some naturalistic elements.

Description of intensive behavioral approaches for young children with autism

Lovaas (1987) described the first major study applying an intensive behavioral intervention program for young children with autism. In the program described by Lovaas, young children with autism received an average of 40 hours per week of direct intensive instruction by the therapist for at least two years. Each child was assigned several trained student therapists who worked with the child in the home, school, and community. Parents were extensively trained so that intervention could take place for almost all of the child's waking hours, 365 days a year.

The goals in the first year were to reduce self-stimulatory and aggressive behaviors, build compliance, teach imitation, and extend intervention into the family. The goals in the second year emphasized teaching expressive and abstract language, interactive play with peers, and extension of the intervention into the community. When possible, children with autism were enrolled in regular preschools to provide exposure to typically developing children. The goals in the third year were to teach appropriate expression of emotion, pre-academics, and observational learning.

As described in the literature, the intervention approach used by Lovaas relied on basic behavioral principles and methods. Aggressive and self-stimulatory behaviors were reduced by ignoring the behavior, using time-out, shaping more socially acceptable behavior, or delivering a loud "no" or a slap on the thigh contingent on undesirable behavior.

Several other investigators have adapted the intensive behavioral intervention program described by Lovaas. The primary changes included: reducing the number of hours per week and the length of follow-up, using personnel other than university students as therapists to administer the intervention, and eliminating the use of physical aversives.

The three basic elements of intensive behavioral and educational intervention programs include:

1. systematic use of behavioral teaching techniques and intervention procedures
2. intensive direct instruction by the therapist, usually on a one-to-one basis
3. extensive parent training and support so that parents can provide additional hours of intervention

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

Recommendations

Using principles of applied behavioral analysis for interventions

1. It is recommended that principles of applied behavior analysis (ABA) and behavior intervention strategies be included as an important element of any intervention program for young children with autism. [A]

Frequency, intensity, and duration of intervention

2. It is recommended that intensive behavioral programs include as a minimum approximately 20 hours per week of individualized behavioral intervention using applied behavioral analysis techniques (not including time spent by parents). [A]
3. It is recommended that the precise number of hours of behavioral intervention vary depending on a variety of child and family characteristics. Considerations in determining the frequency and intensity of intervention include age, severity of autistic symptoms, rate of progress, other health considerations, tolerance of the child for the intervention, and family participation. [A]

4. In deciding upon the frequency and intensity of a behavioral intervention, it is important to recognize that:

   • In the studies reviewed, effective interventions based on ABA techniques used between 18 and 40 hours per week of intensive behavioral intervention by a therapist trained in this method.
   • Based on the available scientific evidence, it is not possible to accurately predict the optimal number of hours that will be effective for any given child. [A]

5. It is recommended that the number of hours of intensive behavioral intervention be periodically reviewed and revised. Monitoring the child's progress may lead to a conclusion that hours need to be increased or decreased. [A]
6. It is important to consider revising the intervention plan when the child shows either significant improvement or a lack of improvement. [A]

Supervision of therapists

7. It is recommended that all professional and paraprofessionals who function as therapists in an intensive behavioral intervention program receive regular supervision from a qualified professional with specific expertise in applied behavioral approaches. [D2]

Parent involvement and training

8. It is important to include parents as active participants in the intervention team to the extent of their interests, resources, and abilities. Parental involvement is important to ensure that the behavioral and educational outcomes, goals, and strategies most important to the family are incorporated in the intervention. [A]
9. It is recommended that parents be trained in behavioral techniques and encouraged to provide additional hours of instruction to the child. Parent training is important to help the family incorporate these techniques into the daily routines of the child and family and to ensure consistency in the intervention approach. [A]
10. It is recommended that training of parents in behavioral methods for interacting with their child be extensive and ongoing and include regular consultation with a qualified professional. [A]

Use of physical aversives

11. The use of physical aversives (such as hitting, spanking, slapping, or pinching) is not recommended as a part of a behavioral intervention program. There is evidence that behavioral intervention programs can be successful without the use of physical aversives. [A]

Basic Principles of Specific Behavioral Intervention Techniques

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

Recommendations

Selecting behavioral and educational intervention techniques

1. It is recommended that intervention strategies for young children with autism use appropriate behavioral techniques, such as those of applied behavioral analysis. [A]
2. Specific behavioral strategies that are useful for children with autism include techniques such as:
• prompting
• modeling
• fading
• reinforcement [A]

Individualizing interventions for each child

3. It is important to identify each child's individual strengths and learning styles. [B]
4. It is recommended that interventions be individualized and tailored to the child's learning style. [D1]
5. It is recommended that the target behaviors for each child be clearly identified and defined, with measurable criteria for mastery. [A]
6. For teaching some skills to young children with autism, it may be useful to perform a task analysis to identify the small component parts of the task to be taught. [C]

Selecting reinforcers for a child

7. It is important to recognize that there are several types of potential reinforcers such as sensory, edible, and social (such as verbal praise). [B]
8. It may be useful to conduct a reinforcer assessment to determine which items will serve as reinforcers for a particular child. [B]
9. It may be useful to vary the reinforcers used. [C]

Techniques and strategies to promote generalization of skills

10. It is important to use behavioral techniques and strategies that facilitate generalization of skills. [A]
11. It is important to assess whether skills being acquired with specific techniques are being generalized to other situations (such as different physical and social environments). [A]
12. A continuum of intervention strategies may be important as the child progresses (such as from being more individualized to interacting with peers in social groups). [A]
13. Using multiple cues may be useful to move the child beyond reliance on pointing prompts and to help the child generalize responses to different stimuli. [C]
14. As the child's skills progress, it is recommended that behavioral techniques include a gradual fading of higher levels of support (prompts and reinforcers) as well as systematic generalization of new behavior to more complex environments. [A]

Assessing progress and modifying the intervention

15. It is recommended that ongoing assessment be included as a part of every intervention session and that intervention techniques be modified as appropriate based on the child's progress. [A]

Behavioral and Educational Intervention Techniques for Maladaptive Behaviors

Maladaptive behaviors are a defining characteristic of autism and may include such things as stereotypic behavior, disruptive behavior, aggression, and noncompliance. Some maladaptive behaviors for children with autism may interfere with their socialization or learning, while other maladaptive behaviors may represent hazards to the child or others.

Reducing inappropriate behaviors is often one of the highest priorities for parents and one of the first targets for interventions. As a first step, a functional analysis is often conducted to determine the function of particular inappropriate behaviors for the child. Then behavioral strategies are devised to reduce maladaptive behavior by using differential reinforcement of appropriate behavior and/or punishment of inappropriate behaviors. In some cases, this may involve reinforcement of a substitute appropriate behavior that is incompatible with the maladaptive behavior.

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

Recommendations

Behavioral/educational interventions for reducing maladaptive behaviors

1. In developing a behavioral strategy for reducing maladaptive behaviors, it is important to consider:
• the child's age, developmental level, skills, and abilities
• environmental changes that might reduce likelihood of maladaptive behaviors and/or the risks to the child from such behaviors
• the parent's needs, desires, and priorities
• family members who would be appropriate to involve in the intervention program [D1]

2. It is recommended that behavioral interventions for reducing maladaptive behaviors be used for young children with autism when such behaviors interfere with the child's learning or socialization or present a hazard to the child or others. [A]

Using functional analysis to evaluate maladaptive behaviors

3. When attempting to reduce maladaptive behavior for a child with autism, it is useful to conduct a functional analysis to determine the function a particular inappropriate behavior has for that child. [A]
4. It is important to recognize that functional analysis of a child's behavior often finds that adult attention is a reinforcing variable that helps to maintain the child's inappropriate behaviors. Using adult attention to differentially reinforce appropriate behaviors is sometimes useful in decreasing inappropriate behaviors for children with autism. [C]

Using reinforcers and punishers to reduce maladaptive behaviors

5. Performing a reinforcer assessment, and then using those reinforcers and punishers found to be effective for a particular child, is an important part of a behavioral intervention to reduce maladaptive behaviors. [C]
6. Using empirically defined reinforcers and punishers can be useful for reducing the frequency of many types of maladaptive behaviors including the eating of inappropriate objects (pica). [C]
7. In children with autism who display maladaptive behavior, it is useful to employ differential reinforcement to help reduce the frequency of inappropriate behaviors and increase the frequency of substitute appropriate behaviors. [C]
8. The technique of differentially reinforcing a child's appropriate verbal requests, and not reinforcing challenging behaviors, can be useful in reducing the frequency of inappropriate challenging behaviors. [C]
9. Using several different punishers in a varied fashion, rather than using a single punisher in a constant fashion, can be a useful technique for behavioral interventions to reduce maladaptive behavior in children with autism. [C]

Use of the Terms "Reinforcer" and "Punisher"

Using physically intrusive procedures or physical aversives

10. It is recommended that any physically intrusive procedure used to reduce maladaptive behavior (such as holding, restraining, or physical redirection) be used only after less intrusive measures have been attempted. If used, then 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]
11. The use of physical aversives (such as hitting, spanking, slapping, or pinching) is not recommended as a method to reduce maladaptive behavior. [D1]

Including parents in the intervention

12. It is important that parents be informed about interventions for maladaptive behavior in order to:

Send questions or comments to: bei@health.state.ny.us
Revised: November 1999