INTERVENTIONS/THERAPIES: COMPREHENSIVE TREATMENT PROGRAMS
CTP refers to a classification of treatment programs that may involve intensive therapy of 20-40 hours per week. Most of the programs are designed to addressed behavior modification, although they encompass a broad area of interventions that include developmental, educational, sensory related, social communication, social skills, listening, and more. In this section you will learn about Applied Behavioral Analysis (ABA) and the other applications of ABA including Verbal Behavior (VB) (discussed by James W. Partington, PhD, BCBA, who is an advisory board member of USAAA), Discrete trial instruction, Pivitol response therapy (PRT), TEACCH, Daily Life Therapy, The Miller Method, Relationship Development Intervention (RDI), Floortime/DIR, Cognitive-Behavioral Therapy (CBT), The Son-Rise Program, SCERTS, The P.L.A.Y. Project, SPELL.
Does you child have behavioral challenges? Many individuals with Autism Spectrum Disorders face behavioral challenges including self-injurious, head banging, hitting, kicking, and running into traffic. In this section you will learn about Applied Behavioral Analysis (ABA) and Verbal Behavior (VB) discussed by James W. Partington, PhD, BCBA, who is an advisory board member of USAAA; Music Therapy, plus other behavior therapy interventions.
Applied Behavior Analysis and Verbal Behavior
Dr. Partington discusses ABA and VB: Applied Behavior Analysis is a method of teaching based on the premise that speech, academics and life skills can be taught using scientific principles. ABA is based on the 20th-century work of B.F. Skinner. In 1938, Skinner published The Behavior of Organisms, which described the process of learning through the consequences of behavior. Later applications of his approach to education and socially significant behavior led to what we now call Applied Behavior Analysis. ABA rewards, or reinforces, appropriate behaviors and responses because children are less likely to continue those behaviors that are not rewarded. Over time, the reinforcement is reduced so that the child can learn without the constant rewards. Research shows that children with autism respond to ABA intervention. Skills are disassembled into their smallest components, so that the children learn to master simple skills, then build toward more complicated skills. Skinner’s 1957 book, Verbal Behavior, focused on the functional analysis of verbal behavior, and led to significant research by Applied Behavior Analysts, including Dr. Jim Partington. This research can be found in the journal, The Analysis of Verbal Behavior, and serves as the foundation for teaching Verbal Behavior as part of an ABA program. Applied Verbal Behavior, then, is ABA with a focus on Verbal Behavior, and the application of ABA in teaching verbal behaviors.
According to the National Association of Cognitive Behavioral Therapists, Cognitive-behavioral therapy does not exist as a distinct therapeutic technique. The term "cognitive-behavioral therapy (CBT)" is a very general term for a classification of therapies with similarities. There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. However, most cognitive-behavioral therapies have the following characteristics:
CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change. Brief report: effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism.
Daily Life Therapy
Daily Life Therapy was developed by Dr. Kiyo Kitahara of Tokyo in the 1960s. Originally a regular kindergarten school teacher, she derived her method from working with a child with autism who was included in her classroom (Kitahara, 1984). Placing heavy emphasis on group dynamics, the method incorporates physical education, art, music and academics, along with the acquisition and development of communication and daily living skills (Boston Higashi School, 1999). Specifically, Dr. Kitahara’s method focuses on social isolation, anxiety, hypersensitivity and hyposensitivity, and the apparent fragility of children with autism. According the Dr. Kitahara (1984), stability of emotions is gained through the pursuit of independent living and development of self-esteem. Mastery of selfcare skills allows for the development of self-confidence and a desire to attempt other adaptive skills. The second focal point, extensive physical exercise, is used to establish a rhythm of life. Many of the exercises are founded upon principles of sensory integration and vestibular stimulation that lead to coordination and cooperative group interaction. Vigorous exercise releases endorphins, which help reduce anxiety. In addition, exercise has been found to reduce incidences of selfstimulatory behavior and aggression (Allison, Basile, & MacDonald, 1991; Elliot, Dobbin, Rose, & Soper, 1994; Koegel & Koegel, 1989), along with hyperactivity and night wakefulness while increasing time on task. Children also learn how to control their bodies as they master riding a bicycle, rollerblading, the balance disk and other Higashi exercises. Physical education is carried out in different sized groups, thus serving as a bridge to social development. Stimulation of the intellect with academics, including language arts, math, social studies and science is compatible with typical school curricula to prepare each student for inclusion opportunities. In the Higashi program, medication is not recognized as a therapeutic technique for working with children on the autism spectrum. Finally, art and music provide opportunities to gain mastery and appreciation for aesthetics. — Stephen M. Shore, EdD (from the USAAA Conference Proceedings Manual 2010)
Discrete Trial Therapy
Discrete Trial is a process used to develop many skills, including cognitive, communication, play, social and self help skills. TeachTown, used in many educational settings (public schools), explains the discrete trial training into their program: The program breaks down individual skills into small discrete tasks and guides a student’s learning through prompting and reinforcement. Each trial follows the traditional discrete trial model that has been used in multiple studies (e.g., Lovaas, 1987; Smith, Groen, & Wynn, 2000) where the discriminative stimulus is presented (i.e. the instruction or cue that the child should respond to) by presenting 1 or more images (e.g., a happy, a sad, and an angry face) with a vocal instruction (e.g., “Find the person that is happy”). Next, the child is expected to respond by selecting one of the images (e.g., clicking on the happy face) (the child can also touch the screen on touch screen monitors). If the response is correct, a positive statement is heard (e.g., “You did it!”), there is a brief (3 second) inter-trial interval (i.e. pause between trials) and the next trial is presented. If the response is not correct, the correct answer is shown.
Floortime™ (or DIRFloortime™) is a specific technique to both follow the child’s natural emotional interests (lead) and at the same time challenge the child towards greater and greater mastery of the social, emotional, and intellectual capacities. With young children these playful interactions may occur on the floor, but go on to include conversations and interactions in other places. DIRFloortime™ emphasizes the critical role of parents and other family members because of the importance of their emotional relationships with the child. The DIR® Model, however, is a comprehensive framework which enables clinicians, parents and educators to construct a program tailored to the child’s unique challenges and strengths. Central to the DIR® Model is the role of the child’s natural emotions and interests which has been shown to be essential for learning interactions that enable the different parts of the mind and brain to work together and build successively higher levels of social, emotional, and intellectual capacities. It often includes, in addition to Floortime™, various problem-solving exercises and typically involves a team approach with speech therapy, occupational therapy, educational programs, mental health (developmental-psychological) intervention and, where appropriate, augmentative and biomedical intervention.
The Miller Method
The Miller method, which embodies developmental, cognitive and systems components, builds on the work of Heinz Werner, Jean Piaget, Lev Vygotsky and Ludwig von Bertalanffy (Miller & Eller-Miller, 1989). The developmental aspect of the approach looks at children with autism spectrum disorder as being completely or partially stuck at earlier stages of development and therefore structures its interventions to spur on development. The cognitive aspect strives to promote cognitive development by structuring the environment so as to be conducive to increased cognitive development. This emphasis on thought processes contrasts with other, more behaviorally oriented approaches, which devote most of their focus to stimuli and response as the explanations of the way child with autism functions in the world. Finally, the systems address the roles systems play in restoring normal development in two ways. The first is to build on the repetitive behaviors (systems) the children have managed to achieve. A system is defined as a coherent organization (functional or non-functional) of behavior involving an object or event (A. Miller, personal communication, July, 1999). Systems range from quite small (mini-systems) such as flicking light switches on and off to quite elaborate such as taking groceries from a bag and putting them where they belong in cupboard or refrigerator (A. Miller, personal communication, July, 1999). The hallmark of a successfully formed system is a desire in the child to continue the activity after it has been interrupted. The second way is to teach children certain behaviors by introducing repetitive activities. These activities or systems are designed to teach behaviors to a child who has not been able to otherwise develop them spontaneously by him or herself. (Miller & Eller-Miller, 1985) — Stephen M. Shore, EdD (from the USAAA Conference Proceedings Manual 2010)
Pivitol response therapy (PRT)
Pivotal Response Treatment (PRT)®, also referred to as Pivotal Response Therapy, Pivotal Response Training®, Pivotal Response Teaching® or Pivotal Response Intervention is a behavioral intervention model based on the principles of ABA. PRT® was previously called the Natural Language Paradigm (NLP), which has been in development since the 1970s.
The P.L.A.Y. Project
Created by Richard Solomon, MD in 2001, and based on the DIR® (Developmental, Individualized, Relationship-based) theory of Stanley Greenspan, MD, The P.L.A.Y. Project program emphasizes the importance of helping parents become their child’s best P.L.A.Y. partner. The P.L.A.Y. Project has four key components: Diagnosis, Home, Consulting, and Training Research. The P.L.A.Y. Project follows The National Academy of Sciences recommendations for the education of young children with autistic spectrum disorders. Parents and professionals should: Begin interventions early (18 months to 5 years;) Use intensive intervention 25 hours per wee;k Have a teacher/play partner to child ratio of 1:1 or 1:2; Use interventions that are engaging; Have a strategic direction (e.g. social skills, language, etc.).
Relationship Development Intervention (RDI)
Developed by Dr. Steven Gutstein and Dr. Rachelle Sheely, relationship development intervention is a parent-based model program that provides a means for individuals with autism and asperger disorder to learn about and experience authentic emotional relationships in a gradual, systematic way. The enjoyable activities in this program emphasize foundation skills such as social referencing, regulating behavior, conversational reciprocity and synchronized actions.
SCERTS® is an innovative educational model for working with children with autism spectrum disorder (ASD) and their families. It provides specific guidelines for helping a child become a competent and confident social communicator, while preventing problem behaviors that interfere with learning and the development of relationships. It also is designed to help families, educators and therapists work cooperatively as a team, in a carefully coordinated manner, to maximize progress in supporting a child. The acronym “SCERTS” refers to the focus on: “SC” - Social Communication – the development of spontaneous, functional communication, emotional expression, and secure and trusting relationships with children and adults; “ER” - Emotional Regulation - the development of the ability to maintain a well-regulated emotional state to cope with everyday stress, and to be most available for learning and interacting; “TS” – Transactional Support – the development and implementation of supports to help partners respond to the child’s needs and interests, modify and adapt the environment, and provide tools to enhance learning (e.g., picture communication, written schedules, and sensory supports). Specific plans are also developed to provide educational and emotional support to families, and to foster teamwork among professionals.
The Son-Rise Program
The Son-Rise Program Start-Up is a 5-day group training program for parents, relatives and professionals looking to facilitate meaningful progress in their children (ages 18 months through 60 years) challenged by Autism, Autism Spectrum Disorders, Pervasive Developmental Disorder (PDD), Asperger's Syndrome, High Functioning Autism and other related developmental difficulties. Exciting, inspiring and diverse presentations by a group of seasoned and dedicated teachers, will deliver to you the autism strategies, expertise, motivation and knowledge honed through years of working with thousands of families and children with Autism Spectrum Disorders. At the end of this course, you will have all the tools necessary to design and implement your own home-based Son-Rise Program, as well as the skills and attitude to impact your child’s growth in all areas of learning, communication, development and skill acquisition.
The SPELL framework recognizes the individual and unique needs of each child and adult and emphasizes that all planning and intervention be organized on this basis. They believe that a number of interlinking themes are known to be of benefit to children and adults with an autistic spectrum disorder and that by building on strengths and reducing the disabling effects of the condition, progress can be made in personal growth and development with the promotion of opportunity and as full a life as possible. The acronym for this framework is SPELL. SPELL stands for Structure, Positive (approaches and expectations), Empathy, Low arousal, Links. SPELL draws on and is complementary to other approaches, notably TEACCH. (National Autistic Society).
TEACCH is an evidence-based service, training, and research program for individuals of all ages and skill levels with autism spectrum disorders. Established in the early 1970s by Eric Schopler and colleagues, the TEACCH program has worked with thousands of individuals with autism spectrum disorders and their families. TEACCH provides clinical services such as diagnostic evaluations, parent training and parent support groups, social play and recreation groups, individual counseling for higher-functioning clients, and supported employment. In addition, TEACCH conducts training nationally and internationally and provides consultation for teachers, residential care providers, and other professionals from a variety of disciplines. Research activities include psychological, educational, and biomedical studies. The administrative headquarters of the TEACCH program are in Chapel Hill, North Carolina, and there are seven regional TEACCH Centers around the state of North Carolina. Most clinical services from the TEACCH centers are free to citizens of North Carolina.
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