There are two major criteria for a child receiving a diagnosis of “Autism Spectrum Disorder” (commonly referred to as ASD or Autism).
These are: 1. Persistent difficulty with social communication and interaction in multiple contexts and 2. Repetitive or restricted behaviors and interests
Both of these must have been present from a young age, affect the individual’s ability to function independently, and cannot be attributed to another disability. Children with ASD can also have difficulty with their sensory processing and motor control, but this alone does not signify ASD.
Supports or interventions tend to focus on these two key areas — social communication and behaviors — with the goal of helping people with ASD become as independent and socially engaged as possible.
Let’s begin with some general truths about interventions for autism:
- Progress is always possible.
- Linguistic and behavioral changes tend to be the most gradual (though not in every case).
- Early intervention is always better.
- Intervention needs to be consistent, and is time-consuming (there are no shortcuts or easy solutions).
Understanding the Types of Support
Some out-of-school supports predominantly target the social-linguistic difficulties, while others primarily target the repetitive behaviors exhibited in children with ASD. The best types of supports target both (even if not directly). As a speech-language pathologist, I have found that most of my experience has targeted the social and linguistic piece. Even when providing strictly communication-based therapy, however, this type of intervention has often resulted in a reduction of repetitive behaviors, since language ended up replacing some actions that were not socially accepted.
Floortime or DIR Model
Like autism, interventions for autism spectrum disorders fall on a spectrum, too. On one end of this spectrum is the Floortime, or DIR (Developmental, Individual-Difference, Relationship), model. These out-of-school supports, developed by Stanley Greenspan, are based on the underlying goal of encouraging children to become engaged with people around them. DIR is based “on the assumption that we can favorably influence the core developmental foundations for relating, thinking, and communicating, even for children with severe problems, by working with their emotions, or affect,” wrote Dr. Stanley Greenspan and Dr. Serena Wieder, authors of “Engaging Autism”, a handbook about the philosophy behind the DIR model.
The DIR model is built on the premise of engaging your child by following her lead and joining her where she is. For example, if a child is clearly interested in playing with an Elmo doll — as demonstrated by her going over to the doll and attempting to grab it — parents and clinicians who use this technique would “playfully obstruct” the child. This would elicit recognition from the child and potentially elicit a communicative act (e.g., pointing, speaking, or using an AAC device). The adult would then follow the child’s lead, and play with the Elmo doll in whatever manner she is able to play with it. By being playful with children with ASD and letting them direct interactions, you can create obstacles that will provoke communication and create emotionally meaningful communications.
On the other end of the continuum are Applied Behavioral Analysis–based supports. This type of intervention (also referred to as “ABA”) is based on behaviorism, which is a philosophy that operates on the idea of stimuli (an “input”) and responses (an “output”). It operates on the assumption that if a child asks for something, and then she receives what she asked for, she may be more likely to use the same method to ask for it in the future. ABA works on “conditioning” children to increase communication and decrease undesired actions or words.
For example, within the ABA model, students are rewarded for communicating, often via a token or reward system that is not always related to the communication or event at hand. In the Elmo doll scenario described above, if a child successfully communicated by saying, “I want Elmo,” then the natural reward would be to give her the doll. After a minute, the Elmo doll would be taken away, and the child would need to say, “I want Elmo” again. With ABA, however, the rewards are often not as directly related (e.g., being given a cookie for saying a greeting), a disconnect that makes the communicative act inauthentic, potentially ineffective, and less likely to generalize (i.e., to be used without a reward).
Research and Other Models
Both of these supports require lots of time and trained professionals to facilitate. There are outspoken supporters of both processes, as well as research to demonstrate their effectiveness, but in each case, the data tend to be skewed toward the outcomes that method focuses on. ABA results in relatively fast progress, but entails minimal initiation (the child’s ability to begin communication without being prompted) and generalization (application of a skill in a variety of situations). So, research studies of ABA tend to look at time or number of things said. As a speech language pathologist, I prefer the DIR model for its encouragement of more spontaneous utterances (verbally or using an AAC device), and for its social engagement benefits.
Other initiatives that address ASD include the TEACCH Program (which lies in between DIR and ABA), the Son-Rise Program (which is similar to DIR), and the Tomatis method (which is an auditory stimulation program, and therefore not really on this spectrum of interventions). While these programs are based on methodical scientific research, they have not yet yielded clear evidence of effectiveness. (See, for instance, this critique of TEACCH and this assessment of the impact of Tomatis training.)
Diane Cullinane of the Interdisciplinary Council of Development and Learning has written: “There is no single best treatment package for all children with ASD,” since “no definitive behavioural or developmental intervention improves all symptoms for all individuals with ASD,” but “a preliminary report ... shows significant effectiveness of the ‘social-communication approach’ based upon the DIR/Floortime framework.”
Obtaining and Receiving Support Services
The first step in getting support services is checking if your child qualifies for an IEP (Individualized Education Plan). If your children is aged 0–3, you need to contact the Department of Health. If she is preschool-aged (3–5) or school-aged (6+), you would go about pursuing support services via the Board of Education.
Once your child is evaluated for special education supports, the school can make any number of recommendations, including: assigning her a small, structured classroom, or assigning her “related services” (which can include special education services, speech-language pathology, occupational therapy, physical therapy, and counseling, among other things). Early intervention can be provided in a clinic, but is predominantly done at home. After all, the primary aim of early intervention is to give the parent and caregiver training so that the child isn’t only getting the best supports when a therapist is around.
For preschool- or school-aged students, support services can be provided in preschool or school, or if the facility does not have sufficient resources, these services can be provided at a clinic or in your home. Schools have also begun employing liaisons to do parent education for children of this age, particularly when there is technology training to be done. This is an excellent resource if it is available to you.
All of the supports mentioned above are free, although sometimes they are time-consuming to get. They also may require you to be an advocate for your child. Know your rights about what public schools are supposed to provide.
What the success measures are will be influenced by which professionals you work with. As a parent, you have the right to approve or reject goals that are on an IEP. In addition, since the best therapies for ASD are reinforced by multiple individuals in your child’s life, your knowledge of the goals is important.
Goals need to be specific, and they need to be measurable. For example, a goal could entail counting the number of times communication was initiated in a finite period (with whatever modality your child is using at the moment, whether it’s pointing, verbalization, and/or an AAC device); length of time that you were able to sustain her attention on a shared task; number of times your child exhibited a certain maladaptive behavior (with the goal being to reduce the number of times the behavior occurred); or length, complexity, or type of thing that your child said (verbally or with an AAC device).
You will know if a therapy is working because you will be able to see your child reaching a goal. If your child is not meeting that goal, then the professional who assigned the objective will be in charge of modifying what the goal is or how the goal is achieved. Maybe your child needs additional supports (e.g., visual cues or physical prompting). Maybe it’s a matter of using more familiar experiences, or about using more motivating activities.
No matter what, know that your child can progress, and that the supports you are able to provide will help her succeed.
Butler, S.P. (2007). Critical Review: The Effectiveness of TEACCH on Communication and Behaviour in Children with Autism. University of Western Ontario.
Center for Disease Control and Prevention. (2013). Autism: Diagnostic Criteria. Retrieved from CDC.
Cullinane, D. (2014). Evidence Base for the DIR(R) Floortime Approach. Retrieved from PCDA.
Gerritsen, Jan (2009). A Review of Research done on Tomatis Auditory Stimulation. Sacarin.
Greenspan, S. & WiEder, S. (2006). Engaging Autism. Da Capo Lifelong Books: Philadelphia, PA.
Greenspan, S. Floortime: What It Really is, and What it Isn’t. ICDL.
Hess, E. (2013). DIR®/Floortime™: Evidence based practice towards the treatment of autism and sensory processing disorder in children and adolescents. International Journal of Child Health and Human Development, 6(3). Retrieved from Center for the Developing Mind.
Mesibov, G.B. & Shea, V. (2009). The TEACCH Program in the Era of Evidence-Based Practice. Journal of Autism and Developmental Disorders. Interacting with Autism.