Refrigerator mothers and beyond…. The aetiology of autism Intervention

Intervention

Specific strategies

Triad of impairment

Evidence-based strategies

Five general strategies: – Teach communicative and Social competence – Use instructional strategies that maintain the natural flow of classroom activities. – Teach and provide opportunities for independence – Proactively and systematically build a classroom community that includes all children – Promote generalization and maintenance of skills

Strategy 1: Teach communicative and Social competence Use of the Picture Exchange Communication System (PECS) to teach an effective mode of communication. – children communicate using pictures and symbols, and focus on initiations. – Use of imitation to teach children with Autism to relate to others. – Imitation is a critical tool. – Children with Autism don’t know how to imitate others (actions, and communication not words)

Strategy 2: Use Instructional Strategies that Maintain the Natural Flow of Classroom Activities Teaching within context of developmentally appropriate activities and routines Draw peers into the instructional situation Teach using a variety of Naturalistic Teaching procedures including: – Mend-Model procedures, time delay, incidental teaching, and interrupted routines and behaviour chains Characteristics of Naturalistic Teaching procedures: – Teaching occurs in the natural environment – Individual teaching interactions are brief and spaced over hours or days – Typically child initiated – Uses natural consequences –toys highly desired by the child – Scaffolding is used in applying techniques different cues or prompts – Only provide help required so that children do not become dependent on prompts

Strategy 3: Teach and provide opportunities for Independence 5 things that can help children with Autism have independence – Give choices when possible, teach choice making when needed. – Provide picture schedules and use timers to indicate duration of activities – Make sure the day is filled with activities, and are conducted in the same way and in the same sequence daily. – Make a special effort to give all children frequent chances to respond to teachers – Maintain high expectations. Celebrate small victories and immediately increase the expectations. Don’t say “he can’t; instead say How can we help him to …?”

Strategy 4: Proactively and Systematically build a classroom that includes all children Never question if a child “is ready” to participate, determine what supports or accommodations are needed for the child to be successful. Plan activities that engage children with a large range of abilities. Plan activities that the child with the most significant disabilities can do independently and are challenging for the typically developing child.

Strategy 4: cont Group activities are important to create a classroom community. Large Group activities and Small Group activities. Large Group activities include: opening circle, songs, stories, and acting out plays Small Group activities include: games, art projects, pre- academic activities Activities need to be short at the beginning of the year and increase in length during the year.

Strategy 5: Promote Generalization and Maintenance of Skills Unless skills are demonstrated in a variety of settings and maintained throughout the year these skills will be used only in the setting where they were learned. 4 strategies that promote generalization and maintenance are: – Target skills that will be useful in each child’s life. – Use prompts judiciously (use least directive and intrusive prompt) and fade them rapidly – Use naturally distributed trials – not all instruction is formally scheduled – Use common material for instruction

Behavioural approaches Early intensive behavioural intervention seems to enable the development of intelligence, communication, and adaptive function, and, to a lesser extent, language, daily living skills, and socialisation. A shift from atypical to typical neurophysiology has been reported after 2 years of intervention with the Early Start Denver Model. However, too few randomised controlled trials have been done. The second comprehensive approach, structured teaching, originates from the TEACCH (Treatment and Education of Autistic and related Communication- handicapped Children) model. It is widely used across a broad age range, but little evidence is available

Targeted approaches Targeted approaches focus on specific cognitive behavioural domains. For non-verbal individuals, the Picture Exchange Communication System could be helpful, at least in the short term. Some evidence of effectiveness is available for models promoting emotion recognition, theory of mind, imitation, and functional communication. Joint attention or engagement training seems to be effective, and could be generalisable to natural contexts and language development. A curriculum targeting socially synchronous engagement for toddlers also seems to be effective. Social skill training for older children, adolescents, and adults is also promising. Programmes establishing independence are often used but still need systematic assessment. Vocational intervention is important, especially for transition into adulthood. Targeted behavioural intervention can also be beneficial by reducing anxiety and aggression.

Parent-mediated intervention Parent-mediated intervention has the advantage of bringing treatment into home and community settings to enable transfer of skills to real-life settings, an increasing parents’ and caregivers’ self- confidence Programmes can be comprehensive (eg, parent delivery of the Early Start Denver Model) or targeted (eg, at joint attention or communication). Sensory integration therapy—frequently used in occupational therapy—is sometimes offered as one component of a comprehensive programme to address sensory-based problems. However, its effectiveness is inconclusive Additionally, they emphasise that social-communication training (with a focus on social skills) should be offered, and non-verbal individuals should have opportunities to use the Picture Exchange Communication System (or alter native communication interventions if that is unsuccessful).

ApproachTarget groupEffectiveness Behavioural approaches ABA intervention based Young children usually aged < 5 yearsLow to moderate e.g. floortime, ESDM Comprehensive structured teaching TEACCH Children, adolescents and adultsLow Provides structures of the environment and activities Targeted skill-based intervention PECS Non-verbal individualsModerate Teaches spontaneous social- communication skills Targeted structured teaching Joint attention, pretend play, theory of mind, functional communication ChildrenNot established, but potentially effective Targets social cognitive abilities fundamental to social-communication