Improving Social Skills and Behavior

A number of treatment approaches have evolved in the decades since autism was first identified. Some therapeutic programs focus on developing skills and replacing dysfunctional behaviors with more appropriate ones. Others focus on creating a stimulating learning environment tailored to the unique needs of children with autism. Researchers have begun to identify factors that make certain treatment programs more effective in reducing — or reversing — the limitations imposed by autism. Treatment programs that build on the child's interests, offer a predictable schedule, teach tasks as a series of simple steps, actively engage the child's attention in highly structured activities, and provide regular reinforcement of behavior, seem to produce the greatest gains. Parent involvement has also emerged as a major factor in treatment success. Parents work with teachers and therapists to identify the behaviors to be changed and the skills to be taught. Recognizing that parents are the child's earliest teachers, more programs are beginning to train parents to continue the therapy at home. Research is beginning to suggest that mothers and fathers who are trained to work with their child can be as effective as professional teachers and therapists.

Developmental Approaches to Autism

Professionals have found that many children with autism learn best in an environment that builds on their skills and interests while accommodating their special needs. Programs employing a developmental approach provide consistency and structure along with appropriate levels of stimulation. For example, a predictable schedule of activities each day helps children with autism plan and organize their experiences. Using a certain area of the classroom for each activity helps students know what they are expected to do. For those with sensory problems, activities that sensitize or desensitize the child to certain kinds of stimulation may be especially helpful. In one developmental preschool classroom, a typical session starts with a physical activity to help develop balance, coordination, and body awareness. Children string beads, piece puzzles together, paint and participate in other structured activities. At snack time, the teacher encourages social interaction and models how to use language to ask for more juice. Later, the teacher stimulates creative play by prompting the children to pretend being a train. As in any classroom, the children learn by doing. Although higher-functioning children may be able to handle academic work, they too need help to organize the task and avoid distractions. A student with autism might be assigned the same addition problems as her classmates. But instead of assigning several pages in the textbook, the teacher might give her one page at a time or make a list of specific tasks to be checked off as each is done.

Behaviorist Approaches to Autism

When people are rewarded for a certain behavior, they are more likely to repeat or continue that behavior. Behaviorist training approaches are based on this principle. When children with autism are rewarded each time they attempt or perform a new skill, they are likely to perform it more often. With enough practice, they eventually acquire the skill. For example, a child who is rewarded whenever she looks at the therapist may gradually learn to make eye contact on her own. Dr. O. Ivar Lovaas pioneered the use of behaviorist methods for children with autism more than 25 years ago. His methods involve time-intensive, highly structured, repetitive sequences in which a child is given a command and rewarded each time he responds correctly. For example, in teaching a young boy to sit still, a therapist might place him in front of chair and tell him to sit. If the child doesn't respond, the therapist nudges him into the chair. Once seated, the child is immediately rewarded in some way. A reward might be a bit of chocolate, a sip of juice, a hug, or applause-whatever the child enjoys. The process is repeated many times over a period of up to two hours. Eventually, the child begins to respond without being nudged and sits for longer periods of time. Learning to sit still and follow directions then provides a foundation for learning more complex behaviors. Using this approach for up to 40 hours a week, some children may be brought to the point of near-normal behavior. Others are much less responsive to the treatment. However, some researchers and therapists believe that less intensive treatments, particularly those begun early in a child's life, may be more efficient and just as effective. So, over the years, researchers sponsored by NIMH and other agencies have continued to study and modify the behaviorist approach. Today, some of these behaviorist treatment programs are more individualized and built around the child's own interests and capabilities. Many programs also involve parents or other non-autistic children in teaching the child. Instruction is no longer limited to a controlled environment, but takes place in natural, everyday settings. Thus, a trip to the supermarket may be an opportunity to practice using words for size and shape. Although rewarding desired behavior is still a key element, the rewards are varied and appropriate to the situation. A child who makes eye contact may be rewarded with a smile, rather than candy. NIMH is funding several types of behaviorist treatment approaches to help determine the best time for treatment to start, the optimum treatment intensity and duration, and the most effective methods to reach both high- and low-functioning children.

Nonstandard Approaches to Autism

In trying to do everything possible to help their children, many parents are quick to try new treatments. Some treatments are developed by reputable therapists or by parents of a child with autism, yet when tested scientifically, cannot be proven to help. Before spending time and money and possibly slowing their child's progress, the family should talk with experts and evaluate the findings of objective reviewers. Following are some of the approaches that have not been shown to be effective in treating the majority of children with autism:

• Facilitated Communication, which assumes that by supporting a nonverbal child's arms and fingers so that he can type on a keyboard, the child will be able to type out his inner thoughts. Several scientific studies have shown that the typed messages actually reflect the thoughts of the person providing the support.
• Holding Therapy, in which the parent hugs the child for long periods of time, even if the child resists. Those who use this technique contend that it forges a bond between the parent and child. Some claim that it helps stimulate parts of the brain as the child senses the boundaries of her own body. There is no scientific evidence, however, to support these claims.
• Auditory Integration Training, in which the child listens to a variety of sounds with the goal of improving language comprehension. Advocates of this method suggest that it helps people with autism receive more balanced sensory input from their environment. When tested using scientific procedures, the method was shown to be no more effective than listening to music.
• Dolman/Delcato Method, in which people are made to crawl and move as they did at each stage of early development, in an attempt to learn missing skills. Again, no scientific studies support the effectiveness of the method.

It is critical that parents obtain reliable, objective information before enrolling their child in any treatment program. Programs that are not based on sound principles and tested through solid research can do more harm than good. They may frustrate the child and cause the family to lose money, time, and hope.

Selecting an Autism Treatment Program

Parents are often disappointed to learn that there is no single best treatment for all children with autism; possibly not even for a specific child. Even after a child has been thoroughly tested and formally diagnosed, there is no clear "right" course of action. The diagnostic team may suggest treatment methods and service providers, but ultimately it is up to the parents to consider their child's unique needs, research the various options, and decide. Above all, parents should consider their own sense of what will work for their child. Keeping in mind that autism takes many forms, parents need to consider whether a specific program has helped children like their own. At the back of this pamphlet is a list of books and associations that provide more detailed information about each form of therapy and other resources.

Exploring Autism Treatment Options

Parents may find these questions helpful as they consider various treatment programs:

• How successful has the program been for other children?
• How many children have gone on to placement in a regular school and how have they performed?
• Do staff members have training and experience in working with children and adolescents with autism?
• How are activities planned and organized?
• Are there predictable daily schedules and routines?
• How much individual attention will my child receive?
• How is progress measured? Will my child's behavior be closely observed and recorded?
• Will my child be given tasks and rewards that are personally motivating?
• Is the environment designed to minimize distractions?
• Will the program prepare me to continue the therapy at home?
• What is the cost, time commitment, and location of the program?