This blog explores techniques and ideas that come from the Positive Behaviour Support Framework which you can read more about here
Autism is considered a ‘spectrum disorder’ because there is a wide variation in the type and severity of symptoms each individual experiences, which renders therapy and intervention needs varied and complex.
However, there is presently no accepted, one universal method of treating ASD. A variety of therapy and intervention approaches can be used to help the individual develop skills to improve independence and enable participation in daily activities that will ultimately increase a person's sense of self-determination.
Recent studies have shown that the greatest potential for improvement can be attained by early diagnosis and therapy. However, it is important to remember that it is never too late, even for those who are older when they get a diagnosis. Effective interventions can lead to progress for people of all ages and skill levels.
NOTE: This article is not a comprehensive list of all available therapy and interventions but a summary of some of the ones that are widely used.
Autism Disorder Spectrum Therapy and Intervention Overview
Current therapy and intervention approaches for ASD target areas such as language and communication, mobility and movement, personal care, social skills, with a focus on improving overall independence and quality of life.
Many types of evidence-based therapy and intervention approaches for ASD currently exist and can be delivered across a variety of settings, such as in the clinic, early intervention, school, home, and community, based on the need of the family and the goals.
Therapy and intervention approaches are often classified as follows:
- Behavioural
- Educational and Developmental
- Social-Relational
- Pharmacological
- Psychological
- Early Intervention
- Nutritional
Note: At different stages of your child’s development one or more of the following approaches could be more helpful. Be mindful of the number of goals you are targeting at the one time, because as for some, the old adage that “more is not always better” can still ring true.
Focusing on a few goals at a time can have a big impact and lead to a series of successes. Collaborate with the treating professional to discuss the specific needs of your child to prioritise therapy and intervention goals.
1. Behavioural Therapies and Interventions for ASD
Based on Applied Behaviour Analysis (ABA) principles, behaviour therapy is the most widely researched intervention approach for ASD.
It works by understanding the reason why a behaviour occurs. ABA is used to teach replacement skills that promote independence and safety while reducing maladaptive behaviours that impact an individual’s daily functioning.
Human behaviour research and ABA was revolutionised in the early 20th century by pioneering behavioural psychologists like B.F. Skinner and Ivan Pavlov. Discrete Trial Training (DTT) was developed in the 1960s and 1970s by UCLA psychologist Dr. Ivar Lovaas and his student Robert Keogel.
The strict framework resulted in the breakdown of desirable skills and actions into smaller, digestible parts. The basic structure of these methods has evolved to integrate additional modern approaches that draw inspiration from ABA.
The "new" ABA strategy involves using ingrained learning principles, behavioural approaches, and environmental changes to shape and promote new behaviours. ABA relies on the concepts of reinforcement (increasing the probability of a behaviour occurring again) and extinction (decreasing the probability of a behaviour occurring again).
It incorporates a range of teaching methods, including:
Discrete Trial Training (DTT).
DTT uses simple, explicit instructions to teach a desired behaviour or response, often in isolation from other skills. Once a skill has been mastered, a therapist will work on helping the client generalise the new skill to different settings and with different material.
Early Intensive behaviour Intervention (EIBI).
Children as young as 18 months old can benefit from EIBI's tailored behavioural teaching for ASD. It takes much time and gives instruction one-on-one or in small groups.
Pivotal Response Training (PRT).
PRT occurs in a natural rather than a clinical setting and often incorporates naturalistic or “incidental” teaching. The main aim of PRT is to teach “pivotal skills” that will help someone learn many other skills, such as requesting or appropriate play.
Positive behavioural and Support (PBS).
Individual needs and root causes of behaviours of concern are both addressed in the evidence-based implementation methodology known as Positive behaviour Support (PBS). To improve the quality of life for both the supported person and their caregivers, PBS takes a person-centered and abilities approach.
PBS aims to identify and address the underlying causes of a child's behaviours of concern. The goal is to create the right environment for a child by modifying their surroundings, activities, teaching new skills, and introducing other positive changes.
2. Educational and Developmental Therapy and Intervention for ASD
A popular approach utilised in educational settings is Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH). This approach is based on research showing how people with autism perform well with concrete instruction, routine, and visual support.
Since its inception more than 40 years ago, the TEACCH technique has been continuously refined based on research and practice with individuals with ASD.
It is a groundbreaking initiative that helps people of all ages learn about and access resources for ASD. The TEACCH methodology has its roots in a child research study initiated in 1964 by Eric Schopler and Robert Reichler at the University of North Carolina.
The children in this pilot trial showed significant improvement in skills, so the state provided funding to help establish Division TEACCH. Eric Schopler established TEACCH in 1971 to support children with autism and their families.
TEACCH approach has been extremely beneficial to children with ASD across a variety of educational settings. It can focus on teaching or strengthening specific skills needed for development, such as communication and language skills, sensory integration, and motor skills.
These approaches often combine with and complement behavioural interventions to allow for a holistic approach to therapy.
Speech and Language Pathology
A speech pathologist (SP) is an allied health professional (AHP) who provides assessment and therapy for communication, feeding and swallowing difficulties. An SP will first assess your child’s current communication skills.
The SP will then collaborate with the family to provide therapy to develop the child’s communication skills. This means developing the child’s ability to understand and express themselves.
This may mean developing the child’s verbal communication skills (i.e. speech), non-verbal communication skills (i.e. facial expressions, vocalisations, gestures, signs and body language) and/or using alternative communication methods (e.g. picture systems, communication boards and communication devices).
If the child has feeding and swallowing difficulties, the SP will also collaborate with the family, other AHPs (e.g. dietitian, occupational therapist, physiotherapist) and other people involved in feeding the child.
Occupational Therapy (OT)
An OT is an AHP who provides assessment and therapy to help children become as independent as possible in daily activities.
An OT will first assess how the child currently participates in everyday activities at home, school and in the community (e.g., shops, parks, church) (Rodger & Ziviani, 2006).
Examples of everyday activities include playing, getting dressed, eating, and managing personal care needs; engaging in household chores, school and work tasks; and participating in extracurricular activities such as playing sports, musical instruments and dancing (Rodger, 2010).
Based on the assessment results, the OT, in collaboration with the family, will plan and develop strategies to facilitate participation in daily activities. Sensory Integration Therapy is also often used by OTs to help the child better deal with sensory input that might make it hard for them to participate in activities.
3. Social-Relational Therapy and Interventions for ASD
Social skills-based therapies focus on improving necessary social skills for creating relationships and participating in communal settings.
Some popular examples of socially related therapies are: The Developmental, Individual Differences, Relationship-Based Model (popularly known as “Floortime”).
This approach is individual-led and involves parents and therapists in the interests of the individual to promote communication.
Relationship Development Intervention (RDI)
The primary symptoms of autism can be alleviated through this family-based behavioural intervention.
The program is geared toward helping people develop their social and emotional intelligence.
Most RDI programs educate parents to take on the role of primary therapist. By strengthening foundational connections, RDI facilitates individuals with ASD in developing meaningful interpersonal connections and the sharing of experiences.
Social Stories
A Social Story explicitly describes a social situation, skill, or concepts to help the child with ASD learn ways of behaving in those situations.
These individualised stories often are commonly used in all settings and provides the individual with expectations for social situations, such as the first day of school, a doctor’s visit, taking turns in a playground etc.
They often include scripts for rehearsal and visual aids.
Social Skills Groups
These provide opportunities for people of all ages with ASD to develop social skills in a mediated and fun environment. While all children work together as a group, the therapist can target specific goals for each individual during each activity.
4. Pharmacological Therapies and Interventions for ASD
We still do not know what definitively causes autism, so there is not one specific drug that can treat the leading causes. This means that there is no “cure."
Nevertheless, many medications can help relieve or lessen symptoms that affect a person's emotional, physical and mental wellbeing.
Medication prescribed by a licensed medical practitioner.
Medications are categorised into:
Anticonvulsants
One-third or more of persons with ASD also experience seizures or epilepsy. Epilepsy and other seizure disorders are treated with these pharmaceuticals.
Psychoactive or antipsychotics
Some antipsychotic medications can treat agitation in individuals with ASD. These drugs have been shown to improve various behaviours of concern.
Medical professionals may prescribe medicine to address underlying causes that are contribute to the occurence of behaviours of concern. Behaviours of concern include:
- Self‐harming behaviour (i.e., hitting head against a wall, scratching face)
- Physical Aggression (i.e., kicking, slapping, pinching others)
- Verbal Aggressive behaviour (i.e., shouting, making threats, profanity)
- Inappropriate sexualised behaviour (i.e., masturbating in public, non-consensual kissing)
- Property Damage (i.e., throwing and breaking items, drawing or carving on furniture)
- Repetitive behaviours (i.e., repeating words or phrases, spinning)
Studies have shown that medication works best when utilised as part of a positive behaviour support approach.
Selective serotonin re-uptake inhibitors (SSRIs)
When taken as a combination, these antidepressants effectively address issues related to chemical imbalances in the body. Antidepressants can improve symptoms such as depression, anxiety, irritability, tantrums, and aggression.
Stimulants
There is evidence that this class of drugs can improve attention and reduce hyperactivity in persons with autism. Medications in this class have shown promise in treating anxiety and panic disorders, which are common in people with ASD.
Tricyclics
These drugs are another kind of antidepressant used to treat mental health issues, including depression and OCD. Some people respond better to them than to SSRIs, and can relieve specific symptoms more effectively.
Families, children, and adults with more than one diagnosed condition (comorbidities), such as depression, anxiety, trouble sleeping, and food sensitivities, can also be given medication.
It takes teamwork between family members, caregivers, and medical professionals to ensure the medication plan is effective and safe. In order to determine if a medicine is effective, doctors typically prescribe it for a short period.
It may take many weeks for some drugs to work, or they may initially make symptoms worse. Your child's doctor may need to experiment with various drug doses and combinations for the best results.
5. Psychological Therapies and Interventions for ASD
Cognitive behaviour Therapy (CBT) is often used to treat autism-related conditions like anxiety, low self-esteem, and trouble controlling intrusive or ritualistic thoughts.
CBT is a mental-health approach that helps the individual understand the connections between their thoughts, feelings, and behaviours and work together to change how they think about and react to triggering situations in their lives.
This therapy is helpful for adolescents and young adults with autism spectrum disorder (ASD) who also suffer from anxiety, obsessive-compulsive disorder (OCD), and even depression (Walters et al., 2016).
Cognitive therapy was pioneered in large part by American psychologist Albert Ellis. In the 1950s, he developed rational emotive behaviour therapy (REBT) theory, which emphasised the interconnectivity of one's thoughts, feelings, and actions.
The theory describes that a person's interpretation of an event rather than the event itself causes them emotional pain. Psychiatrist Aaron T. Beck identified trends among his depressive patients in the 1950s and 1960s.
Despite attempts to investigate their backgrounds, they continued to have pessimistic views about themselves, other people, and the future. Because of this, he began investigating whether or not having a pessimistic worldview contributed to someone's depression.
Moreover, thus, Cognitive behaviour Therapy was born. Many different CBT methods exist. CBT is a form of psychological therapy that helps the individual build a set of skills to take CHARGE of one’s thoughts, feelings, and behaviours to achieve symptom reduction, improvement in functioning and overall quality of life.
6. Early Intervention Approaches for ASD
Early diagnosis and intervention for autism have been shown to be extremely beneficial. A young child's brain is still developing, making it more "plastic" or open to change than an adult's brain.
This flexibility increases the potential for long-term therapeutic benefits. Early interventions help children get off to a great start and give them the advantage of reaching their fullest potential.
The earlier a child receives assistance, the better their chances for recovery and future development. Current recommendations stress the importance of beginning a multidisciplinary approach to development and behaviour modification as soon as a child is suspected of having ASD or has been diagnosed (Goldstein & DeVries, 2013).
7. Nutritional Interventions for ASD
Many children with ASD have sensory issues that contribute to them becoming a resistant/avoidant eater.
This is due several reasons. Firstly, due to sensory sensitivities and preferences the child may eat from a limited food selection (1-15 foods or less), refuse one or more food groups, and become anxious when presented with new foods.
Due to the limited diet, it can have a negative impact on the individual’s health, development, and quality of life. In such cases it is beneficial to work with a dietitian.
A dietitian is an AHP who provides assessment and therapy in the areas of food, nutrition and dietetics.
In order to assist the child, the dietitian may need to collaborate with other AHPs, such as speech pathologists, Occupational therapists and psychologists to evaluate the child’s nutritional needs, feeding skills and feeding environment.
Based on their evaluation findings, the dietitian can then work with the team to develop an individualised eating and drinking plan to promote the child’s nutritional well-being and prevent nutrition related problems.
The advice may include recommendations about how to gradually increase the number and different types of foods the child eats; how to increase the nutritional content of the existing foods they eat; and other nutritional supplements that may be beneficial.
If appropriate, recommendations for alternate forms of nutrition, such as tube feeding, may also be discussed.
Secondly, children with ASD may have food sensitivities and allergies which requires them to be on restricted diets, such as gluten-free, casein-free, sugar-free, or a mixed approach diet.
Consultation with the dietitian and other medical professionals is recommended to make specific dietary changes that do not exacerbate digestive issues.
The Future of ASD Therapy and Interventions
Research is continually providing evidence for emergent therapies and interventions for ASD. While options may have been limited in the past based on age, accessibility, and lack of understanding of autism, today’s families have an increasing range of intervention approaches available that can be tailored to their specific needs. Exciting results for individuals with ASD are being shown from therapy approaches such as art therapy, Equine assisted therapy, minduflness based therapy and music therapy.
As scientists, researchers and professionals continue to deepen their knowledge regarding autism and its genetic and environmental origins, the range of therapies and interventions available to families and their loved ones is expected to grow.
References
Choueiri, R.N., Zimmerman, A.W. (2017). New Assessments and Treatments in ASD. Current Treatment Options in Neurology, 19, 6. https://doi.org/10.1007/s11940-017-0443-8
Goldstein, S., & DeVries, M. (2013). Autism spectrum disorder enters the age of multidisciplinary treatment. In Interventions for autism spectrum disorders (pp. 3-18). Springer: New York.
Howlin, P. (2005). The effectiveness of interventions for children with autism. Neurodevelopmental disorders, pp. 101–119.
Hyman, S.L., Levy, S.E., Myers, S.M., & AAP Council on Children with Disabilities, Section on developmental and behavioural pediatrics. (2020). Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics, 145(1), e20193447.
Matson, J.L., Konst, M. J. (2014). Early intervention for autism: Who provides treatment and in what settings. Research in Autism Spectrum Disorders, 8 (11), pp 1585-1590. Murray, M.L., Hsia, Y., Glaser, K. et al. (2014). Pharmacological treatments prescribed to people with autism spectrum disorder (ASD) in primary health care. Psychopharmacology, 231, 1011–1021. https://doi.org/10.1007/s00213-013-3140-7
Rodger, S. (2010). Introduction to occupation-centred practice with children. In S. Rodger (Ed). Occupational centred practice with children: A practical guide for occupational therapists (pp. 1-20). Oxford. UK: Wiley Blackwell.
Rodger, S. & Ziviani, J. (2006). Children, their occupations and environments in contemporary society. In S. Rodger, & J. Ziviani (Eds.), Occupational therapy for children: Understanding children's occupations and enabling participant (pp. 3-21). Oxford, UK: Blackwell Science.
Walters, S., Loades, M., & Russell, A. (2016). A systematic review of effective modifications to cognitive behavioural therapy for young people with autism spectrum disorders. Review Journal of Autism and Developmental Disorders, 3(2), 137–153.