#4B Programs (1-4), Therapies & Interventions with < My Thoughts > by Sara Luker
The following is described by the Centers for Disease Control & Prevention – Retrieved from: https://www.cdc.gov/ncbddd/autism/treatment.html
This post is focused on…
- Behavior & Communication; Applied Behavior Analysis (ABA), Developmental Individual Differences Relation-Based-Approach (aka DIR/Floortime), Occupational Therapy (OT), Picture Exchange Communication System (PECS).
#4B (1 - 4 )PROGRAMS, THERAPIES & INTERVENTIONS ABA, DIR, OT, PECS;
with < My Thoughts > by Sara Luker:
The following programs, therapies & interventions are described in alphabetical order, without intent or suggestion of status or effectiveness –
< My Thoughts > … 8 PROGRAMS you may find under BEHAVIOR & COMMUNICATION –
- Applied Behavior Analysis (ABA)
- Developmental Individual Differences Relation-Based-Approach (aka DIR/Floortime)
- Occupational Therapy (OT)
- Picture Exchange Communication System (PECS).
- Relationship Development Intervention (RDI)
- Sensory Integration Therapy for Sensory Processing Disorder (SPD)
- Speech Therapy (ST)
- Treatment & Education of Autistic & related Communication-handicapped Children (TEAACH)
< My Thoughts > Here are a few thoughts of parents, regarding early intervention programs.
Carlon, Carter, & Stephenson (2015) say that parents reported in a study of 62 parents that they didn’t pick a program on the recommendation of others. They felt there was enough ‘empirical’ information out their now to make an informed decision. This study found that the most frequently used programs… and these were often used simultaneously, were Applied Behavior Analysis (ABA), Relationship Development Intervention (RDI) & Complementary & Alternative Medical treatments (CAM); along with some support for Sensory Processing (sometimes called Sensory Integration Therapy).
Note: Understand that many of these programs have therapists holding long sessions in your home, while you are present. If you have siblings or other children present too, this can be problematic. Sometimes these program sessions can be also held at school with trained staff. The problem there can be that of ‘continuity’ and ‘fidelity’ to your child’s individual program. The staff may not be dedicated to that program alone, and/or may work with your child in a group setting. Also, there could be a lack of program continuity due to school holidays and extended breaks. Just saying
1. Applied Behavior Analysis (ABA) A well known treatment approach for people with Autism Spectrum Disorder (ASD) is called Applied Behavior Analysis (ABA). ABA has become widely accepted among health care professionals and used in many schools and treatment clinics. ABA encourages positive behaviors and discourages negative behaviors, in order to improve a variety of skills. The child’s progress is faithfully tracked and measured. Typically this therapy requires a long-term commitment. For a child under three years old, from 26 – 30 hours a week, in the home setting. Over three years old, from 30 – 40 hours per week. Age range is from 2 – 12 years old. Many insurance companies seem to be more familiar with this very intense type of behavioral therapy. Therefore, parents can often find the funding they need when ABA is part of the overall plan for their child’s intervention.
There are different types of therapies under the ABA umbrella.
Following are some examples (also shown in alphabetical order):
- Discrete Trial Training (DTT) or Discrete Trial Intervention (DTI) (Under the ABA umbrella)
DTT is a style of teaching that uses a series of trials to teach each step of a desired behavior or response. Lessons are broken down into their simplest parts and positive reinforcement is used to reward correct answers and behaviors. Incorrect answers are ignored. This method targets eliciting first words in children with ASD who have little or no spoken language. For ages from 2 – 6 years old; 20 – 30 hours per week.
- Early Intensive Behavioral Intervention (EIBI) (Under the ABA umbrella)
This is a type of ABA for very young children with an ASD, usually younger than 5 years old, and often younger than 3 years old. This is a one-on-one treatment based on EIBI theories and begins in the home setting, generalizing to the community as the child learns the desired replacement behaviors. Usually eligibility requires a recommendation from a psychologist or psychiatrist and a sustained partnership between the therapy team and the family.
- Pivotal Response Training (PRT) (Under the ABA umbrella)
PRT aims to increase a child’s motivation to learn, monitor his own behavior, and initiate communication with others. It is designed to help the child reduce maladaptive behaviors that may interfere with functioning and replace them with a high level of adaptive skills. The child’s desire to obtain a reward is the key to this training. Rewards can be food, praise, playing a game or having another preferred activity. Positive changes in these behaviors should have widespread effects on other behaviors. Ages 2 – 6 years old and is usually part of the ABA process. PRT is considered to satisfy the criteria for ‘evidence-based’ practice.
- Verbal Behavior Intervention (VBI) (Under the ABA umbrella)
VBI is a type of ABA that focuses on teaching verbal skills. One-on-one, 2 – 4 hour sessions continuing until the child is able to perform the fundamental speech functions. The child learns how to verbalize through – asking for needs and wants (Manding); labeling things (Tacting); reaching for and pointing to things (Motor imitation); asking and requesting things in a back-and-forth intentional conversation (Intraverbals); and following instructions to perform a task (Receptive tasks). Often used in conjunction with or before the Early Intensive Behavioral Intervention (EIBI) portion of the ABA program is taught. (Under the ABA umbrella). The benefit would be that the child learns that s/he can request and receive things without a tantrum or dragging a person to show them what object or activity they want or need. This reduces nonfunctional aggressive behaviors which can result in self-injury.
Carlon, S., Carter, M., Stephenson, J. (2015). Decision-Making Regarding Early Intervention by Parents of Children with Autism Spectrum Disorder; Journal of Autism & Developmental Disabilities; 27:285-305.
Rivard, M. & Forget, J. (2012). Verbal Behavior in Young Childrem with Autism Spectrum Disorders at the Onset of an Early Behavioral Intervention Program; The Psychological Record; 62: 165-186.
Ryan, J., Hughes, E., Katsiyannis, A., McDaniel, M. (2011). Research-Based Educational Practices for Students With Autism Spectrum Disorders; Teaching Exceptional Children; Nov./Dec. 2014.
Verschuur, R., Huskins, B., Verhoeven, L., Didden, R. (2017). Increasing Opportunities for Question-Asking in School-Aged Children with Autism Spectrum Disorder: Effectiveness of Staff Training in Pivotal Response Treatment; Journal of Autism & Developmental Disabilities; 47:490-505.
Floortime Play Therapy focuses on emotional and relational development (feelings, relationships with caregivers). It also focuses on how the child deals with sights, sounds, and smells. This therapy usually takes place in six to ten 20 – 30 minutes sessions, daily; depending on the challenge involved. This works best for children from 2 – 5 years old and is tailored to strengthen the bond between the parent and the child.
The purpose of this therapy is to help the child with social relationships, mutual interactions, and behavior. It takes into account personality disorders and behavioral problems such as:
- agitated and irritable mood
- low adaptability
- lack of self-caring ability
- lingual complications
- various learning disabilities
Floortime Play is a children’s game which lasts 20 – 30 minutes, but is not just for children. Parents, treatment team members, and even other family members work together on this integrated model. Because Floortime Play therapy empowers the whole family, it is said to lead to a more visible improvement for the whole family.
Retrieved from autism.about.com –
According to Dr. Stanley Greenspan, the originator of Floortime:
“What makes Floortime play different from typical play is that the parent is working and the child is having fun. Over time, the parent or the therapist will have fun too. You are challenging your child to do six things at once to the highest level the child can accomplish. He or she may not be capable of all six initially, but eventually we want to get them there.”
Retrieved from – autismresourcefoundation.org
Floortime helps children reach six developmental milestones crucial for emotional and intellectual growth. They are:
- Self-regulation and interest in the world
- Intimacy, or engagement in human relations
- Two-way communication
- Complex communication
- Emotional ideas
- Emotional thinking
So basically, Floortime Play is a special kind of play where you are harnessing all these abilities of the child by tailoring your relationship to the child’s nervous system. You are having fun because you are following the child’s leads and interests. Then when the child looks at you or giggles or talks to you, it’s meaningful. It’s not contrived, it’s not forced, and it’s not a rote skill. That’s what makes Floortime Play special.
We call the model the “DIR Model” – because the “D” part means we focus directly on whether the child needs more work on engagement or two-way communication. The “I” is focusing in on their individual ways of their biologically based ways of dealing with sensations like being over or under reactive. The “R” is learning relationships that are tailored to their nervous system, and meet them where they are at their developmental level. So that’s what makes it a special kind of play.
Aali, S., Yazdi, S., Abdekhodael, M. Chamanabad, A., Moharreri, F. (2015). Developing a Mixed Family-focused Therapy Based on Integrated Human Development Model & Comparing Its Effectiveness with Floortime Play-therapy; Fundamentals of Mental Health; March/April; p. 87-98.
Retrieved from: occupationaltherapyot.com
Occupational therapy teaches skills that help the person live as independently as possible. The role of the Occupational Therapist is to promote, maintain, and develop the skills needed by the autistic child to be function at home, at school, and beyond. Length, and number of therapy sessions per week are determined by the child’s age and need; also will vary in time and setting.
Occupational Therapist services for the autistic child include assessment, intervention and follow- up. Therapists help with feeding/eating skills, dressing and toileting skills, as well as educational, playing and social activities. Some autistic children find it difficult to process and act upon information received through the sensory process while performing everyday tasks. This can result in motor coordination difficulties, behavioral issues, cognitive impairment, anxiety, learning difficulties and more.
PECS uses picture symbols (visual supports on cards, pages or in books) to teach communication skills. The learner is taught to use picture symbols to ask for objects or activities, ask and answer questions, and have a conversation. In 20 – 30 minute sessions, children learn a communication system where they exchange different symbols with a partner as a means to communicate a ‘want’.
PECS is intended to increase speech, language, social and communicative development for persons from 2 yrs. to adult. Sometimes PECS becomes a part of a Speech Therapy Program for the child with autism.
Four main communication behaviors are addressed –
- Picture requests
- Imitated verbalizations
- Picture discrimination
- Related speech
This intervention is taught in six phases by a trained ‘communicative partner’ and has ‘visual supports’ which can be made or purchased readymade.
Retrieved from: Picture Exchange Communication System: Steps for Implementation; Page 16 of 16; National Professional Development Center on ASD (2010) –
PECS is taught in six phases. In Phase 1 the learner is to look at, reach for, pick up, and hand the picture/symbol to their communication partner. These basic skills are needed to effectively communicate using PECS exchange system. As the child moves through the Phases, gesture/mild touch physical assistance and verbal prompts fade to allow for independent exchanges between child and communication partner.
Once learners have progressed through all six phases of PECS training, they are fairly proficient in seeking their communication book, discriminating among pictures, constructing sentence strips, finding a communication partner, and completing the exchange.
PECS can also be used through an iPad program or Augmentative/Alternative Communication (AAC) device.
These are the first 4 programs; ABA, DIR, OT, PECS. The next 4 programs that will be described are... RDI, SPD, ST, TEAACH.
END of #4B POST (1 - 4 )PROGRAMS, THERAPIES & INTERVENTIONS ABA, DIR, OT, PECS;
with < My Thoughts > by Sara Luker
RDI is a model which teaches parents how to guide their child in a reciprocal relationship. Most families spend 2 ½ hours daily participating and making meaningful changes to their lives. RDI takes place in the family’s unique cultural home setting and usually lasts for an initial period of 30+ weeks.
This relationship focused process addresses the key core autism issues of motivation, communication, self-awareness, and flexible thinking. According to Mahoney & Perales (2003), parents are taught to enhance their use of responsive interactive strategies during routine interactions with their children.
This study showed that RDI helped over 200 children diagnosed with autism, mild & moderate delays, and at-risk children due to prematurity or poor environmental conditions. It also took into account the child’s temperament when teaching parents how to respond to everyday events. Some parents reported that they liked learning new strategies which helped them build a relationship with their child and deal with challenging behaviors. Other parents felt that making them the ‘therapist’ so to speak, added too much stress to an already stressful life. Know that siblings can learn this process too.
Mahoney, G., Perales, F. (2003). Using Relationship-Focused Intervention to Enhance the Social-emotional Functioning of Young Children with Autism Spectrum Disorders; Topics in Early Childhood Special Education; Vol.23:2 77-89.
Sensory integration therapy helps the person deal with sensory information, like sights, sounds, and smells. Sensory integration therapy could help a child who is bothered by certain sounds or does not like to be touched. These therapies are based on the unproven theory that people with autism spectrum disorder have a sensory processing disorder that causes problems tolerating or processing sensory information, such as touch, balance and hearing.
Some sensory-seeking behavior is only satisfied by great big deep pressure hugs, and the child performing tics (Tics are odd behaviors which occur when the child is excited or over stimulated; such as head nodding or jerking, eye blinks, or lip smacking). Therapists use brushes, squeeze toys, trampolines and other materials to stimulate these senses. These therapies are not always effective, but it's possible they may offer some benefit when used along with other treatments.
According to Bogdashina & Casanova (2016), recent research has provided evidence for the sensory theory of autism and the possibility of diagnosing autism in very young children, if the ‘sensory symptoms’ are taken into account. Research evidence indicates that sensory perceptual differences may be among the first signs of autism in young children.
For example, behaviors such as rocking and rhythmic head banging, spinning objects or perimeter hugging (especially in large spaces), and the need to touch everything in a room before settling down, are typical for both autistic children and those with visual impairments.
Bogdashina, O. & Casanova (2016). Sensory Perceptual Issues in Autism and Asperger Syndrome, Different Sensory Experiences – Different Perceptual Worlds; Second Edition: London; Philadelphia: Jessica Kingsley Publishers.
Speech therapy helps to improve the person’s communication skills. These therapists are usually Speech Language Pathologists. Some people with autism are able to learn verbal communication skills. For others, using signing gestures, picture boards, electronic ‘talkers’, rhythmic songs, and/or lip and tongue exercises work too. The speech therapist works on any oral-motor difficulty the child may have. Therapists work on the child’s expressive language and try to bring it equal to his or her cognitive level. In other words, your child may understand more that can be expressed with his or her current language skills.
Professionals, such as a Speech Therapist can determine if your child has a learning disability. Common to autism or autism-like symptoms are Auditory and Visual Processing problems. In other words, your child’s ears and eyes may be working just fine, but their brain is not properly receiving the information that they are sending. In order for a child to have good ‘receptive language’ he or she must also have good auditory and visual processing abilities. Sometimes, children cannot identify the sounds they are hearing. Nor do they always have the visual depth perception necessary to help them coordinate during motor activities.
Lee & Hyun (2015) share that in the language therapy field, video and audio content are used as teaching media; as well as communication-assisting technology. In addition this Augmentative and Alternative Communication System (AAC) allows users to have virtual peers and avatars to encourage learning, listening to others, turn-taking and other social skills connected to language.
Now, added to this, is an intelligent robot with an evolved capability for entertainment while providing direct interaction with learners. Besides conversational language, Special Friend iRobiQ has a conversational function which can be delivered in a ‘script approach method’. A hand washing script would start – “Turn on the water”…”Wash hands with soap”… ”Wash hands with water”… ”Wipe hands on towel”… This can be paused or repeated as necessary.
The program also helps therapists and parents because it has an added feature of monitoring the child’s speech function, collecting data and compiling reports. Another reason therapists find this useful is that the robot seems like a toy to the participant and is conversationally predictive. Special Friend iRobiQ is not intimidating and has a capacity for direct interaction without the human emotions, attitudes, facial expressions or other subtle information the human may have which could be confusing to the child.
Sicile-Kira (2014) tells us that there are many apps that have been developed for tablets and smartphones, such as the iPad and iPhone. Augmentative/Alternative Communication (AAC) devices are costly, but they may be covered by insurance. Augmentative devices are used mostly to supplement speech, while Alternative devices are used when there is little or no speech. For information on these devices go to https://www.asha.org/public/speech/disorders/AAC/ which may be recommended for your child. Treatment for particular symptoms, such as speech therapy for language delays, often does not need to wait for a formal ASD diagnosis. While early intervention is extremely important, intervention at any age can be helpful.
Lee, H. & Hyun, E. (2015). The Intelligent Robot Contents for Children with Speech-Language Disorder; Educational Technology & Society; V. 18:3; p 100-113.
Sicile-Kira, C. (2014). Autism Spectrum Disorder (revised): The Complete Guide to Understanding Autism; New York, New York: Penguin Random House Company.
TEACCH uses visual cues to teach skills. For example, picture cards can help teach a child how to get dressed by breaking information down into small steps. Teaches pro-social behavior for children between 2 – 12 years old. A model designed as a strategy for facilitating language development.
According to Stephen Edelson, Ph.D, this structured teaching method was developed by Professor Eric Schopler and his colleagues at the University of North Carolina at Chapel Hill. They tell us that the TEACCH method is successful because it is a ‘therapeutic tool’ to help autistic individuals of all ages, understand their surroundings.
He goes on to say that this method addresses the autistic individuals difficulty with receptive and expressive language, sequential memory, and handling transitions and changes in their environment. TEACCH relies on five basic principles – Physical Structure, Routine, Scheduling, Visual Structure, & Work System.
- Physical Structure refers to clearly defined boundaries for activities like… work, play, snack, music, and transitioning.
- Routine is the most functional skill because it is needed throughout the person’s lifetime. All of the other TEACCH principles lend themselves to support the person’s routine.
- Scheduling is a planner for the person’s entire day, week, and month. This is shown in words, picture, drawings or however the person can interpret it best; visual, auditory, and/or kinesthetic.
- Visual Structure refers to visual cues. For instance the person uses colored containers or dividers to show organizational steps.
- Work System is set up so the person knows what to expect during a task or activity. The goal is to have the person work independently, in an organized way to complete the task or activity.
The TEACCH method helps the autistic person better understand and function in his or her environment through the use of structured physical and visual cueing. The person has constant references to guide him or her to navigate their environment.
Cognitive-Behavioral Therapy (CBT) I am adding this program because the focus of this therapy is ‘Daily Living Skills’. Studies have shown that parents worry about their child’s lack of motivation in this area.
CBT was originally used in the Mental Health Community, in addition to medication, for anxiety, phobias, specific fears, obsessive worrying, and compulsive behaviors. Now, this therapy is used for children with autism spectrum disorder to help them address social issues and to learn daily living skills.
According to Drahota, et al. (2011), there is a strong link between a child’s high anxiety and their low motivation when learning necessary daily living skills.
In this study, developmentally appropriate practical skills necessary for daily personal care ranged from –
- Dressing oneself, to… avoiding unhealthy people
- Putting things away, to… cleaning with cleaning products
- Knowing it’s unsafe to ride with strangers, to… telling time
This study intended to find ways to help children from ages 7 years to 11 years become more self-sufficient. The intent was also to help parents and children maintain gains over the course of years, not just months. As a result of this therapy, the children in the study were found to be more successful because they no longer focused on their anxieties or other related interferences instead of learning.
Another study, by Rotheram-Fuller & MacMuller (2011), said that CBT was originally used for patients with extreme anxieties to include –
- Separation anxiety
- School phobia,
- Specific fears, obsessive worrying
- Compulsive behaviors.
The CBT therapy also had a pharmacological component. In addition to therapy, the patient received antipsychotics, and/or antidepressants to deal with underlying issues related to social problems. In this study, parents were also trained to work with their child using relaxation and problem solving strategies. Together, parent and child learned ways to combat their symptoms by changing their feelings and thoughts about certain events and interactions.
Drahota, A., Wood, J., Sze, K., Van Dyke, M. (2011). Effects of Cognitive Behavioral Therapy on Daily Living Skills; Journal of Autism & Developmental Disorders; 41:257-265.
Rotheram-Fuller, E. & MacMuller, L. (2011). Cognitive-Behavioral Therapy for Children with Autism Spectrum Disorder; Psychology in the Schools; 48(3).
END of #4B Programs, Therapies, & Interventions, Cont. POST (5-8): DRI, SPD, ST, TEAACH, & CBT with < My Thoughts > by Sara Luker
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