Over the past thirty years there has been a growing focus in the field of child and adolescent behavioral health on providing evidenced based interventions. Behavioral health intervention is often time and cost intensive and consumers and funding sources expect providers to utilize techniques that are supported by research and produce the best outcomes.
Autism Spectrum Disorders (ASD) involves significant impairments in communication and social interactions as well as the presence of odd and repetitive behaviors and restricted areas of interest that actively interfere with development and skill attainment across all areas of functioning. Treatment of ASD is often time and cost intensive. Consequently, focusing on interventions that work is essential. Evidenced based interventions for individuals with ASD include Applied Behavioral Analysis, Pivotal Response Training and Reciprocal Imitation Training.
Applied Behavioral Analysis
Applied Behavior Analysis (ABA), also referred to as Early Intensive Behavior Intervention (EIBI) is the primary, evidence based treatment for Autism Spectrum Disorder. ABA focuses on hierarchical intervention behavioral intervention and has proven to be one of the most effective methods for reducing problematic behavior and teaching children with ASD new skills. Lovaas is one of the most cited/referenced researchers in the field of ABA and is credited with the application of these principles in the treatment of individuals with ASD. ABA focuses on children who are three years of age or younger and involves between twenty to forty hours per week of one-on-one behavioral intervention for three or more years.
Children with ASD lack the ability or inclination to learn in the same manner as typically developing children. However, early studies from the 1960s demonstrated that children with ASD are capable of learning in the same manner as other children, and that the principles of ABA could be used to teach skills such as communication and regulation of aggression. The results of early studies did not have a lasting impact on functioning. It was later found that the integration of ABA (elements) into aspects of everyday life, as well as implementation earlier in life, could have a more lasting impact. While children and adults were found to still be capable of learning through ABA methods, it was found to have the most impact at the toddler/ preschool age when the behaviors are less ingrained and brain development promotes flexibility in the development of neural pathways that support the acquisition of new skills.
ABA is ultimately based on hierarchical skill building. Skills are divided into simpler steps which are taught one at a time, each step building on the previous. Children work with a behavior specialist one-on-one in a distraction free environment. Clear and concise instructions are given, mistakes are immediately corrected and immediate positive reinforcement is given for a correct response. ABA can be used to teach a huge range of skills including communication, academic performance, and socially appropriate behavior and remains one of the most studied interventions for children with ASD.
Pivotal Response Training
Pivotal Response Training builds upon applied behavioral analysis by combining it with a more developmental approach. While building on familiar behavioral principles it differs from ABA in that the focus is on maintaining the ‘intrinsic motivation” associated with the interactions. Pivotal Response Training relies on the identification of “pivotal areas” to be targeted in order to increase the effectiveness and efficiency of the treatment. The five primary areas that have been identified are motivation, responsivity to multiple cues, self-regulation, self-initiation, and empathy. When these areas are targeted by treatment, it leads to widespread changes in un-targeted areas and behaviors. In typical development, the motivation to respond to social and environmental stimuli is essential. However, children with ASD sometimes fail to understand the connection between their behaviors and their consequences, which can lead to a feeling of confusion and learned helplessness. Pivotal Response Treatment focuses on decreasing this by enhancing the connection between the child’s responded and reinforcements that are continent on that response. There is emerging evidence to suggest that when these strategies are combined with more traditional ABA approaches the child has positive treatment outcomes.
Reciprocal Imitation Training
The imitation of behaviors is a key component in learning social interaction. It is common for individuals with autism spectrum disorders to have difficulty imitating others. Reciprocal Imitation Training is a treatment that seeks to improve social skills through encouraging children with autism to imitate the behaviors of a parent or treatment provider. Studies suggest that improved imitation skills can lead to an overall improvement in other areas of communication in children with ASD. Reciprocal imitation strategies can be integrated into the child’s daily activities as well as into ABA interventions to promote the imitation of the gestures and behaviors when playing/interacting. Target behaviors include playing with toys, mimicking gestures and initiating vocalizations. Ultimately, the goal is to model interactions and create a back and forth where the parent or treatment provider and the child take turns imitating each other.
Unfortunately, as much great work has been done on developing and disseminating evidence based interventions for children with autism spectrum disorders, there continues to be those that actively advocate for interventions that are not supported by strong scientific evidence and also can be potentially harmful to individuals. Some of these fad treatments include facilitated communication, chelation therapy and gluten and casein free diets.
Facilitated communication was created for individuals who were unable to communicate due to a physical disability. It was believed that if the arm of the individual was supported while typing they would be able to reach their true potential and utilize better communication skills than what they were able to demonstrate independently. While initially intended as a means of aiding communication some saw it as a treatment for individuals with ASD. It plays on the assumption that there is a “typical/ normal” individual within the person with ASD and the belief that providing nonverbal individuals with support on their arm while typing will be able to produce typical language. However, this “treatment” is very easily debunked. If the facilitator cannot hear the question being asked of the individual they are facilitating, then the typed responses, even with “facilitation” do not relate to what is being asked or are completely nonsensical.
A study published in the Lancet in 1998 by Andrew Wakefield made the case that the mercury contained in thimerosal, a preservative found in the measles, mumps and rubella (MMR) vaccinations, was a direct factor in the substantial increase in autism spectrums disorders. Since that time there has continued to be ongoing concern among many people that there is a connection between mercury or heavy metal poisoning and the development of ASD. Consequently, the use of chelation, which is the medical process of heavy metal detoxification, has continued to be perpetuated as a treatment for ASD. Unfortunately, there is no evidence that mercury poisoning or heavy metal toxicity causes ASD nor is there any evidence to suggest that using chelation therapy treats core ASD symptoms. The initial studies Wakefield’s initial study has been retracted and he lost his medical license in the UK for falsifying his research data.
Gluten free and Casein Free Diets
The Gluten and Casein Free (GFCF) diet involves removing all foods containing these proteins from the diet of an individual with autism spectrum disorder and is very difficult to follow. The theoretical basis for gluten free and casein free diets as a treatment of ASD is that in individuals with gastrointestinal problems these proteins are able to pass through the membrane of the intestines and into the bloodstream. Once in the bloodstream, it is believed that these proteins can impact functions of the central nervous system. However, research suggests that there is not significant connection between gastrointestinal disorders and ASD. Furthermore, the use of such diets does not appear to contribute substantially to any treatment gains beyond what would be seen by engaging in interventions (e.g. ABA, etc.) that have strong scientific evidence of positive treatment outcomes.