1. ASD & Clinical Interventions: What Works? Prof. Rita Jordan Emeritus Professor in Autism Studies University of Birmingham Autism Conference: York, 13 February 2013

2. A Developmental Disorder – compensation – secondary 'handicaps' – transactional process

3. Co-Morbidities Wing: “Nature never draws a line without smudging it” ASD rarely occurs as sole disorderASD rarely occurs as sole disorder additional developmental disorders & later anxiety disordersadditional developmental disorders & later anxiety disorders diagnostic hierarchy rules deny reality:diagnostic hierarchy rules deny reality: –language disorder & autism –ADHD & ASD –DSM-V more dimensional approach –problems for PDD-NOS expression of disorders affected by co-morbid conditionsexpression of disorders affected by co-morbid conditions

4. What’s Special about ASD? need to learn explicitly what others acquire intuitively or through social tutoringneed to learn explicitly what others acquire intuitively or through social tutoring –identity of self/ other –saliency of social signals –agency and intention –relevance and priority –social/cultural meaning –nature of communication –emotional consciousness

5. Difficulties & Differences executive functionsexecutive functions –‘ monotropic’ attention –impulse control –idiosyncratic perception imagination & reality testingimagination & reality testing empathy & emotional/ conscious understandingempathy & emotional/ conscious understanding concept developmentconcept development –problems abstracting –rigidity of concept & schema boundaries

6. Strengths sustained attention to interestssustained attention to interests no social distractionsno social distractions usually visual informationusually visual information careful attention to detailcareful attention to detail no social heirarchy - no deceit - get job doneno social heirarchy - no deceit - get job done accurate detailed memoriesaccurate detailed memories ‘fresh’ idiosyncratic art - visual/ poetry/ music‘fresh’ idiosyncratic art - visual/ poetry/ music vulnerability brings out the best in others (often!)vulnerability brings out the best in others (often!)

7. Application of Research on Interventions IQ & high language ability ‘override’ intervention effectsIQ & high language ability ‘override’ intervention effects need for control makes ‘conformist’ training inappropriateneed for control makes ‘conformist’ training inappropriate need to build social activities around interestsneed to build social activities around interests –e.g. Legotherapy e.g. success of multimodal DENVER modele.g. success of multimodal DENVER model

8. Early Intervention Hogsbro (2007) - evaluation of ABA in DenmarkHogsbro (2007) - evaluation of ABA in Denmark –ABA worst results on all measures except parent satisfaction Diggle & McConachie (2009) - no single approachDiggle & McConachie (2009) - no single approach PACT (2010) - only limited gains in childPACT (2010) - only limited gains in child –compared with ‘treatment as usual’ Dawson, Rogers et al (2010)Dawson, Rogers et al (2010) –RCT - comprehensively better –developmental approach vs ‘treatment as usual’ 15hr/week Rogers (2011) - Mind Institute - intensive socialRogers (2011) - Mind Institute - intensive social –90% speaking by 3 years /improve IQ by 20 points in 1st year Lipsey & Wilson (2010)Lipsey & Wilson (2010) –meta-analysis needed Eldevik et al.(2011) children with ASD > in ‘trained’ mainstreamEldevik et al.(2011) children with ASD > in ‘trained’ mainstream –27 rise in IQ, in some, 21 pts in social dev. vs none in individual SA Stahmer et al. (2011) uncontrolled study of trained mainstreamStahmer et al. (2011) uncontrolled study of trained mainstream –16% inmprovement over expectations

9. Education Research most ‘research’ little more than opinionmost ‘research’ little more than opinion few attempts to contact all stakeholdersfew attempts to contact all stakeholders –NAS study but biased sample –AET study poor research on inclusion (Jordan, 2008)poor research on inclusion (Jordan, 2008) –National Strategies - encouraging but research base? –Australian study to compare ‘satellite’ classes with individual support need for research on educational entitlement & ‘education as therapy’need for research on educational entitlement & ‘education as therapy’ need to look at individual factors and goals of educationneed to look at individual factors and goals of education

10. Background Factors dietdiet –peptide theory –effects of diets sleepsleep –chronic deprivation –melatonin exerciseexercise –daily aerobic environmental structureenvironmental structure

11. Person Level Autism a key variable in behaviour:Autism a key variable in behaviour: –poor communication – lack of understanding –poor adaptive behaviours –ritualistic routines –panic & fear - need for structure other individual characteristicsother individual characteristics

12. Treatment level factors in staff affecting efficacy of treatment:factors in staff affecting efficacy of treatment: –causal attribution of challenging behaviour Bromley & Emerson, 1995; Qureshi, 1993Bromley & Emerson, 1995; Qureshi, 1993 –work culture –rule -governed behaviour (not individual or flexible) –training type

13. Effective Treatments behavioural treatments:behavioural treatments: –need to take account of autism go beyond ABC to STAR (Clements & Zarkowska, 1994)go beyond ABC to STAR (Clements & Zarkowska, 1994) settings include:settings include: –past experience (learning history & life events) –social climate –physical climate –personal health –personal attributes & beliefs –emotional state

14. Avoiding trouble stress build upstress build up unpredictabilityunpredictability over-stimulationover-stimulation panic reactionpanic reaction need to relaxneed to relax sleep deprivationsleep deprivation sugar ‘highs & lows’sugar ‘highs & lows’  teach to ‘escape’  visual structure  proximal ‘blockers’  train automatic responses  postures, music, therapies, relaxation  bedtime routines  low GI diet

15. Factors Affecting Success in Implementation Smith, Felce, Jones & Lowe (2002)Smith, Felce, Jones & Lowe (2002) –following training in working with clients with ID in PABA –only effective with clients with Adaptive Behaviour Scale < 180 –only effective if no challenging behaviour –Autism only a barrier if ABS > 180 –not effective if mental illness

16. Teaching to Avoid Challenges pre-empt:pre-empt: –stress - prosthetics & exercise –anger - alternative –frustration - communication –panic - posture / drill train for ‘escape’train for ‘escape’ teach relaxationteach relaxation teach social understandingteach social understanding –Social Stories/ video life/ soaps low stimulation teaching & carelow stimulation teaching & care –ATLASS

17. Factors which may Promote or Inhibit Development in ASD Potentially adverse factors Potentially favourable factors detached, asynchronous parent engaged, synchronous parent adult led activities child led activities directive, non-negotiable negotiated activities assessment focuses on product assessment focuses on process no access to NT children access to NT children high social demand low social demand deficit highlighted difference respected special interests discouraged special interests used as motivators

18. Teaching for Purpose different approach needed to suitdifferent approach needed to suit –individual characteristics sociabilitysociability languagelanguage cognitive levelcognitive level sensory issuessensory issues ageage –goal –practitioner comfort/ ability/ knowledge

19. Individual factors: Sociability Wing’s classificationWing’s classification –withdrawn/ solitary -> passive/ responds -> ‘active but odd’ -> eccentric & sensitive varies with conditions & with teachingvaries with conditions & with teaching level suggests optimum form of approachlevel suggests optimum form of approach –withdrawn - 1:1 directive & desensitisation –passive - interest & structured play experience –active but odd - social rules & experience (context) –eccentric - social skills in context e.g. buddy

20. Evaluating Practice Evidence Supported Treatment (EST)Evidence Supported Treatment (EST) –start with treatment –try to establish if it ‘works’ –gives information on general value –little help in deciding in a particular case –treatment fidelity important Evidence Based Practice (EBP) –start with individual –try to see what is best for him /her –gives information about this case –takes account of context & individual –looks at EST & process

21. Evidence no single approachno single approach evidence for:evidence for: –structure –broad modern behavioural methods –training parents in social interaction & communication techniques –play-based early interventions (15 hrs/ week) in all studies some do well and some do notin all studies some do well and some do not in all studies children tend to learn only what is explicitly taughtin all studies children tend to learn only what is explicitly taught

22. General Approach to Stress reduce stress by:reduce stress by: –use of prosthetic devices –increasing understanding –improving coping skills accept nature of the autistic difficulties i.e. take perspective of person with ASDaccept nature of the autistic difficulties i.e. take perspective of person with ASD priority to communication & interpersonal developmentpriority to communication & interpersonal development

23. Teaching to cope with stress teaching relaxation and ‘escape’teaching relaxation and ‘escape’ –careful not to reward –observation of ‘build up’ –teach alternative –general strategies - relaxation, aerobic exercise, cognitive behavioural therapy coping with paniccoping with panic –automatic response

24. A Positive Approach to Challenging Behaviour move away from aversivesmove away from aversives understand meaning and functionunderstand meaning and function need positive alternativeneed positive alternative –not inhibition –teaching consequences structured settingstructured setting accept phobias etc..accept phobias etc..

25. Teaching Consequences less able - single trackless able - single track more able -more able - –railway - no turns –2 clear termini with no connections –choice point emphasised Moment of choice Problem Taught alternative

26. Conclusion normal intuitive learning requires cognitive effortnormal intuitive learning requires cognitive effort normal levels of stimulation cause stressnormal levels of stimulation cause stress lack of control fromlack of control from –poor self understanding –poor social understanding –poor communication

27. Teaching Students with ASD is Hard mutual problem with empathymutual problem with empathy mutual problem with communicationmutual problem with communication cannot rely on intuition so have to use cognitive routecannot rely on intuition so have to use cognitive route hard to moniter self & studenthard to moniter self & student and hard to keep it upand hard to keep it up