The scientific community found that a number of methods and approaches prove fruitful when treating people with Autism Spectrum Disorder. Influential and widely cited literature regarding efficacy of treatments for Autism refers to behavioral approaches. "Thirty years of research demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior" (US Dept. of Health 1999, p. 164). Equally in Italy, the Ministry of Health (2011) recommends the behavioral approaches for treating Autism. Hence our approach at AutismService is to adhere the principles of Applied Behavior Analysis and Verbal Behavior (ABA/VB). The overall sum of our professional experience and our certified knowledge also enables us to integrate ABA/VB with other methods such as TEACCH, DIR/FloorTime, and Sensory Integration. This agility enables us to address the specific needs of our clients and to consider his/her daily environment when implementing our interventions.
Our forte, which we employ to combine and integrate alternative methods where they may fit better, usually facilitates us in recognizing ability and to explore avenues in maximizing our client's full potential. We here provide an overview of the approaches to which we adhere, including our principal method ABA/VB.
Applied Behavior Analysis (ABA) aims to improve socially significant behaviors that embrace areas of communication, playing, personal self-care, socialising, vocational skills, domestic skills, and academic abilities. Moreover this approach centres on decreasing any challenging and maladaptive behaviors (e.g. aggression, self injurious behaviors, environment distruction, stereotypical behaviors, etc.).
A forte of ABA is that it can be incorporated into a family's lifestyle with all significant actors such as parents and relatives, siblings, peers, caregivers, teachers and therapists being envolved in the intervention. As such the nature of intervention is comprehensive and the ABA principles can be implemented in the context of daily activities. Next to the family home, ABA can be implemented in other settings such as the school environment; the work place; and in public spaces (e.g. library, restaurant, public transport, etc.).
The scientific fundamentals that direct ABA (Cooper et al. 2007) employ a collection of data on the responses made by the individual as to determine whether progress is being made. With other words, ABA allows for the charting of differences made in progress and, if progress is absent following a particular intervention, it allows the therapist to re-evaluate the program and alter it accordingly.
A one-to-one instructional technique used in ABA to teach skills in a planned, controlled, and systematic manner is referred to as Discrete Trial Teaching (DTT). DTT is applied when a learner needs to learn a skill best taught in smaller and easier components. Each trial or teaching opportunity has a definite beginning and end. Positive praise and/or tangible rewards are used to reinforce desired skills or behaviors. A prompt may be given to increase the likelihood that the individual will perform a correct response. The prompt will be gradually faded out in order to obtain an independent and desired response. An important part of DTT is data collection which supports decision making by providing teachers/practitioners with information about beginning skill level, progress and challenges, skill acquisition and maintenance, and generalization of learned skills or behaviors.
The overall ABA approach allows for flexibility in terms of the user's age but there is research aplenty that solidly demonstrates that an early intervention in combination with the initial intensity of the intervention does result in optimal chances for tangible improvements. This mirrors also our experience at AutismService when working with clients at an early stage. With reference to the intensity of the intervention, the original Lovaas studies (Lovaas 1987) show that approximately half the children were able to achieve major improvements with an intensity of 40 hours per week average. Other research (Lord and McGee 2001) supports, at a minimum, 25 hours per week of intensive behavioral intervention for young children with Autism. Also more recent findings (Reed et al. 2007) concluded that high-intensity behavioral approaches (with mean average 30 hours/week) produced greater gains than low-intensity programs (with mean average 12 hours/week).
Verbal behavior (VB) is based on Skinner's behavioral analysis of language and on the principles and similar teaching procedures of Applied Behavior Analysis (Skinner 1957). Verbal behavior identifies language as learned behavior caused by the same environmental variables that control nonverbal behavior (i.e. stimulus control, motivating operations, reinforcement, etc.).
Skinner noted that humans acquire their ability to talk much in the same way that they learn non-verbal behaviors. In other words, verbal behavior is under the control of consequences mediated by other people who can function as speaker and listener. Skinner, instead of focusing on the grammar or syntax of language, identified functions which he called verbal operants: mand, tact, intraverbal, echoic, textual, copying a text and transcription. During the 1970s, a number of behavior analysts began adapting Skinner's approach to introduce Verbal Behavior Therapy (Sundberg and Michael 2001; Carbone et al. 2010).
Most part of verbal operants are taught through Natural Environment Teaching (NET); where a teacher/therapist has a specific target in mind and, by following the student's motivation/interest, use materials in the natural environment away from a structured teaching setting. The table below summarizes the primary verbal operants in the analysis of verbal behavior. For example: if you think about teaching the word "milk" to a child, the same word can have different functions followed by different consequences.
The integration of the Skinner's behavioral analysis of language into the ABA approach, introduced the importance of creating teaching procedures based on the student's motivation and an increased use of a natural environment and reinforcement.
In the 1970s Dr. R. Koegel and Dr. L.K. Koegel (Koegel and Koegel 2006) developed the Pivotal Response Treatment (PRT). Derived from Applied Behavior Analysis, PRT includes the development of communication, language and positive social behaviors. Being based on the child initiation, the PRT therapist provides clear and uninterrupted instructions and opportunities by presenting multiple examples (e.g. use of the same verb in relation to two different objects: "roll car" and then "roll ball") and positively reinforcing approximations or attempts (Neftd et al. 2010). Motivation strategies are an important part of the PRT approach that emphasizes the use of "natural" reinforcement (e.g. if a child requests "ball", he gets the ball and not praise nor a candy or other unrelated reward).
Since its inception, Pivotal Response Treatment has been called Pivotal Response Training, Pivotal Response Teaching, Pivotal Response Therapy, Pivotal Response Intervention and the Natural Language Paradigm. These terms all refer to the same treatment delivery system.
It is estimated that “between 33 and 55 percent of individuals with ASD never develop communication skills that are sufficient to meet their most simple daily needs’’ (Cafiero and Meyer 2008). Children living with autism may not be able to use verbal cues nor do they use gestures or facial expressions (Nunes 2008). This makes communication with others even more difficult for them.
Augmentative and Alternative Communication (AAC) strategies include all forms of communication (other than oral speech) that are used to express needs, desires, thoughts, feelings and ideas. AAC uses facial expressions, gestures or signs, symbols or pictures, writing or typing. People with severe speech impairments or language delay rely on AAC to supplement existing speech or replace speech that is not functional or comprehesible. Studies show that AAC use does not impede the development of speech, and may result in an increase in speech production (Schlosser and Sigafoos 2003; Schlosser and Wendt 2008). Therefore the AAC strategies are used to enhance communication and the users should not stop using speech if they are able to do so.
AAC can utilize:
Considering the motor control of the user, it is important to identify the most adequate selection techniques (direct selection, scanning, and encoding) to indicate the symbols/pictures/words the user wants to use. In fact, the selection rate has direct impact on the rate of communication, and the fastest and effortless selection technique should thus be used. In an AAC system is also important identify the method that will be used to represent language. It is possible to use multiple methods based on the user’s needs (single meaning pictures, alphabet-based system, semantic compaction).
One of the most widely used teaching procedures used by AAC is the Picture Exchange Communication System (PECS). Initially developed in 1985 by Andy Bondy, PhD and Lori Frost, CCC/SLP, PECS is an augmentative and alternative communication system to teach children and adults with Autism and other communication deficits to initiate communication. PECS begins with teaching a student to exchange a picture/symbol of a desired item with a teacher/communicative partner who immediately honours the request.
After the student learns to spontaneously request for a desired item, the system goes on to teach discrimination among symbols and then how to construct a simple sentence. In the most advanced phases individuals are taught to respond to questions and to comment.
There are six teaching phases:
Although an initial concern was that PECS might delay or inhibit speech development, a recent review of several studies found however that PECS facilitate rather than inhibit speech (Sulzer-Azaroff et al. 2009; Ganz et al. 2012). PECS is intended to also be combined with elements of verbal behavior analysis and it can be used to teach verbal operants also to non-vocal children.
Social Cognition is the study of how people process social information, especially its encoding, storage, retrieval, and application to social situations. It is the ability of considering the feelings of others in their actions and communication (Shaffer and Kipp 2009; Aronson et al. 2010).
The content of our minds is not visible: we can only figure out what others know or believe from their behaviors, such as their facial expression, what they do, and from what they say (Chawarska and Shic 2009; Chawarska et al. 2010). Individuals with Autism Spectrum Disorder (ASD) have trouble interpreting social situations. They may lack of basic social skills such as asking a friend to play, or they may have difficulties in responding appropriatly in social situations (e.g. predicting outcomes, preparing for change, problem-solving, etc.).
Skills in social cognition are also essential for learning in many academic areas.
In reading, social cognition skills allow a child to understand the perspective of different characters (e.g. distinguishing the perspectives of ‘Little Red Riding Hood and the Wolf’). Without understanding these notions, stories are often a boring sequence of physical events. Social cognition also play a role in understanding many aspects of history, social and cultural studies, art, and politics. Schools are also social environments and, in addition to learning academic skills, children and youth are learning how to live among others. It is through perspective taking that young children need to learn fundamental principles of sharing, kindness, and solving problems and this through talking rather than physical conflict .
Currently, three major theories exist to explain social cognition deficits:
Social Stories as concept was introduced by Carol Gray in the 90s to help people with Autism to understand better and behave appropriately in a variety of social situations (Gray and Garand 1993). Social Stories are short stories that break down a challenging social situation into understandable steps by omitting irrelevant information; by being highly descriptive; by presenting the perspective of others; and by suggesting an appropriate response. Individuals with Autism Spectrum Disorder are usually strong visual learners but often struggle to understand and to learn how to respond to various social situations. Social Stories illustrate real situations by using drawings, photographs or symbols, and written comments or dialogs appropriate to the ability of the user (Crozier and Sileo 2005; Schneider and Goldstein 2009; Schneider and Goldstein 2010).
There are seven sentence types that may be used to create a Social Story (Gray 2000):
In the 1960s, Dr. A.T. Beck developed cognitive therapy as a structured therapy that uses an information-processing model to understand and treat psychopathological conditions. In contrast to other forms of psychotherapy, cognitive therapy is usually more focused on the present, more time-limited, and more problem-solving oriented.
Cognitive behavior therapy (CBT) is based on the cognitive model that describes how people’s perception of situations influence their emotional, behavioral and often physiological reactions (Beck 2011). CBT may help people who are in distress by identifying their distressing thoughts, by evaluating how realistic their thoughts are, and by learning to change distorted thinking so that it more closely resembles reality. When people do so, their distress usually decreases and they are able to behave more functionally.
Studies show that CBT can be usefully integrated in the treatment plans for adults with anxiety disorders, depression, eating disorders, personality disorders, chronic low back pain and substance use disorders. In children and adolescents, CBT is an effective part of treatment plans for anxiety disorders, depression, eating disorders and obesity, obsessive-compulsive behaviors, tic disorders or other repetitive behavior disorders (Boileau 2011; Flessner 2011; Mennuti et al. 2005; Seligman & Ollendick 2011).
Individuals learn about the world through the senses of hearing, sight, touch, smell and/or movement. However, children with Autism Spectrum Disorder often have unusual responses to the senses, over-reacting or under-reacting to things they hear, see, taste and touch. These responses can interfere with learning and affect behavior. Some children avoid gentle physical contact and yet react with pleasure to rough games. Some children carry food preferences to extremes, with favored foods eaten to excess whereas others limit their diet to a small selection. Some children can be extremely sensitive to certain noises, fabrics, or bright lights. These may be signs of Sensory Processing Disorder, also known as Sensory Integration Dysfunction.
Sensory Integration is an innate neurobiological process and refers to the interpretation of sensory stimulation from the environment by the brain. This information plays an important role in perceiving the environment and in activating protective reactions for survival (Adt and Sengupta 2005; Burr et al. 2006).
The theory of Sensory Integration was developed by Dr A. Jean Ayres in the 1970s creating a variety of playful exercises in order to assist children in processing a more organized response to sensory stimuli (Ayres 1970; Ayres 1973).
Sensory Integration Therapy focuses primarily on three basic senses:
Treatment and Education of Autistic and related Communication Handicapped Children (TEACCH) is a training program for individuals of all ages with Autism Spectrum Disorder developed at the University of North Carolina, originating in a child research project begun by Dr E. Schopler and Dr R. Reichler in 1964.
Working from the premise that people with Autism are predominantly visual learners, intervention strategies are based around physical and visual structure, schedules, work systems and task organisation, employing alternative and augmentative communication techniques in a supportive environment carefully organized to avoid any distraction or sovra-stimulation in the user. (Mesibov et al. 2004; Peeters 2008).
The main educational tool is a task box; a box that contains all the materials needed to complete a task. Task boxes help organize and structure work because they provide a clear beginning and end to the task that will be completed, thus fostering independent work skills.
Developmental, Individual-Difference, Relationship-Based model (DIR or FloorTime) is a form of play therapy developed by Dr. S. Greenspan that uses interactions and relationships to reach children with developmental delays and Autism. (Greenspan and Wieder 2006). Rather than looking just at symptoms, this approach describes how to find the missing developmental steps and, from knowing what essential skills to strengthen, the children are helped to practice basic thinking skills (engagement, interaction, symbolic thinking and logical thinking).
Dr. Greenspan identified six developmental milestones:
Considering the developmental milestones, with the DIR/FloorTime approach the child's actions are assumed to be purposeful and the parents or caregivers follow the child's lead and help him/her develop social interaction and communication skills. For instance: during a FloorTime session, a boy may frequently tap a toy car against the floor. His mother may imitate the tapping action or put her car in the way of the child's car. This will prompt the child to interact with her. From there the mother encourages the child to develop more complex play schemes and incorporate words and language into play.
Floortime is usually used by families who prefer a play-based therapy as a primary or secondary treatment, especially for toddlers and preschoolers.