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  Intensive Educational Therapies for Autsim

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Intensive Educational Therapies and Naturalistic Behavior Therapy


Motivation is the key to teaching autistic children to respond appropriately to social and environmental stimulation. It has been hypothesized that very early in life motivational problems begin when these children repeatedly experience failure; these repeated failures then can lead to depressed motivation, poor performance, and task and social avoidance (Clark & Rutter, 1979; MacMillan, 1971; Rodda, 1977). And, once this cycle of repeated failures starts, it causes the autistic child to respond less or not at all. A persistent lack of motivation can manifest itself in extreme lethargy or in active avoidance of learning tasks. It is typical for such children to become aggressive towards themselves or others, destroy property, and exhibit other severe disruptive behaviors in an attempt to avoid learning tasks. Because an autistic child needs motivation to respond, brief behavioral assessments and standardized assessments used for classroom placement and to develop IEPs (individualized educational programs) may not accurately determine the child's functioning level. Instead, these tests may only assess the child's motivation to respond and not his or her ability to respond. If a child is inaccurately assessed, this can only exacerbate the motivation problem because his/her academic program will consist primarily of reviewing previously learned tasks, instead of learning new tasks. Those children evaluated wrongly as very low functioning may be segregated and not presented with academic challenges and this can be detrimental to the child's long-term development (cf. L.K. Koegel, Valdez-Menchaca, & Koegel, 1994).

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How to Motivate Autistic Children:

Several factors help to motivate autistic children: reinforcement, stimulus, and task variation. R.L. Koegel, O'Dell, and Dunlap (1988) found that when attempts to communicate are reinforced, verbal responding improves. This is in contrast to the more traditional techniques in which reinforcement was only given if verbalizations were correct or nearly correct on successive occasions. Another powerful motivator is stimulus. Motivation is greatly increased if the stimulus items are highly desirable and chosen by the child and not by the clinician or parent. Additionally, varying the tasks motivates autistic children to respond (Dunlap & Koegel, 1980). If the teacher presents new tasks along with those tasks previously mastered, then the child learns the target behaviors faster (Dunlap, 1984; L.K. Koegel & Koegel, 1986). Combined, these factors (reinforcement, stimulus, and task variation) resulted in improved levels of appropriate responding (R.L. Koegel, O'Dell, & Koegel, 1987) and significantly reduced the levels of disruptive or avoidance behaviors (R.L. Koegel, Koegel, & Surratt, Schriebman, 1988).

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Language Usage:

The language characteristics of autistic children can be classified as follows: verbal, nonverbal, delayed verbal, and echolalic. Autistic children, classified as verbal, tend to give elaborate explanations and refuse to change the topic despite cues given by the other communicator ( Bernard-Opitz). Since children are being diagnosed younger and intervention is being implemented earlier, there has been a considerable reduction in those children who are classified as nonverbal. Those children, classified as delayed verbal, have problems in areas such as phonology, syntax, and semantics. Even when autistic children use language, their language differs both in the number of utterances and reasons for communicating from that used by typically developing children (Wetherby and Prutting, 1984). For example, autistic children used communication most frequently for requesting objects, actions, or protesting. While, typically developing children used communication most frequently for labeling. Additionally, autistic children exhibited fewer social responses than typically developing children. Two reasons account for this discrepancy in social responses; one is that autistic children are likely to be involved in fewer social interactions due to the limited number of utterances that they emit. And, the second reason is that autistic children tend to use language to meet their needs (i.e. requesting and protesting), instead of using language to socialize with others. Lastly, those children exhibiting immediate echolalia are able to repeat all or part of the utterance just heard. This repetition most often occurs when the child does not seem to know an appropriate response to the previous utterance or question (Carr, Schreibman, & Lovaas, 1975). Teaching children who are echolalic to reply "I don't know" or "I don't understand" has been proven to reduce echoing and to provide the child with a socially appropriate response which can be utilized in a variety of situations. Autistic children who repeat sounds, words, phrases or even entire commercials, songs, or television programs are exhibiting delayed echolalia; this type of repetition usually functions as a means of self-stimulation.

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Intervention Techniques:

Functional Analysis:

Functional analysis is one device used to elicit changes in behavior; this approach consists of assessing the child's primary motivation or purpose of his/her behaviors. This information can then be utilized to teach more effective behaviors to be used in place of the disruptive behaviors (Carr & Durand, 1985). For example, autistic children often express their frustration, anger, displeasure, and sometimes basic needs through disruptive behavior. These children communicate ineffectively by screaming, tantruming, running away and being aggressive. By performing a functional analysis and replacing these inappropriate behaviors with more appropriate ones, the child is able to learn to appreciate words and other effective ways to communicate. Teaching autistic children more effective communication skills results in increased acceptance and this in turn causes more positive interactions and more learning opportunities for the child.

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Teaching Children to Respond to Multiple Cues

Typically, developing children utilize three or four cues at a time, whereas certain autistic children only respond to very restrictive portions of complex stimuli. This type of response was referred to as stimulus over-selectivity. (Lovaas, Schreibman, Koegel & Rehm, 1971). For example, an autistic child may learn to recognize an adult by a small and extraneous cue such as his or her eyeglasses, a bracelet, or a gesture he/she makes while talking, but are unable to recognize the individual if that single cue is missing (Rincover, Koegel, 1975: Schreibman & Lovaas, 1973). Due to overselectivity, autistic children may have difficulties bonding/and or recognizing people. It may appear that autistic children are unable to form attachments, but this is not a valid assessment. Instead, they are inhibited to form close relationships because they fail to recognize constant features of a particular individual. In addition to having problems connecting with others, autistic children often fail to recognize a dangerous situation due to responding selectively, instead of responding to all environmental cues.

Intervention techniques to deal with this overselectivity have proceeded in two directions. One direction focuses on developing teaching strategies that are effective even if the child continues to be overselective throughout life. For example, a widely used technique referred to as within-stimulus prompting has been shown to be highly successful (R.L. Koegel, Dunlap, Richman, & Dyer, 1981). In within-stimulus prompting, children are prompted to respond to a relevant cue by exaggeration, similar to the way in which a cartoonist exaggerates a relevant feature of a celebrity to make this individual instantly recognizable This technique is helpful in improving learning, but it may not help children to respond to complex stimuli. The second direction focuses on increasing the number of cues that autistic children utilize from the environment. R.L. Koegel and Schreibman found that autistic children could be taught to respond to multiple cues through the use of reinforcement. These results also indicated that once the children learned the strategy of responding to multiple cues that they could then apply this strategy to learning new tasks. Additionally, Burke and Cerniglia (1990) found that teaching children to respond to multiple cue instructions helped them in responding to complex instructions.

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Teaching Children Self-Management and Independent Responding

Since autistic children typically exhibit motivational problems and experience repeated failures in communication, they may become overly dependent on others. However, this dependence can be very detrimental because the child then learns that his/her responses are disconnected from his/her behaviors. Techniques such as self-management help children to participate more actively and become less dependent on their parents and others. L. K. Koegel et al. (1992) found that there was a decrease in the disruptive behavior of four autistic children after they were taught to self-manage; specifically, these children learned to monitor their appropriate responses to questions posed by the adults. Teaching a child to self-manage also helps to reduce parental stress and improves family interactions. Additionally, self-management helps autistic children to connect consequences with their behaviors. Self-management involves the following steps:

  1. Choosing a specific behavior to target, such as aggression, hygiene, or verbal communication with others.
  2. Teaching the child to recognize when he/she behaves appropriately. Do not focus on the absence of the negative behavior, rather reward when appropriate behaviors are displayed.
  3. Once the child has learned to differentiate the desirable behavior from undesirable, then the child is taught to monitor brief periods of time or occurrences of the positive behavior.
  4. After mastering step #3, the child can be taught to self-manage in any environment. The provider should only remind the child to begin self-management and then gradually fade out of the new environment by leaving for longer periods of time.

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Communication and Language Intervention for Nonverbal Children

Recent data indicates that autistic children who are completely nonverbal are capable of learning at least some expressive language if naturalistic procedures are begun before age five. Utilizing naturalistic procedures is referred to as milieu teaching and this form of teaching more closely resembles the manner in which developing children naturally learn language. Milieu teaching involves:

  1. Varying the stimulus items - Camarata and Nelson (1992) taught grammatical structure to children during natural play interactions. They found that the children learned more rapidly when the interventions were similar to that in the natural environment (i.e. an activity that the child had selected) as opposed to an activity chosen by the clinician (i.e. direct imitation and drill format). Autistic children are more successful in learning initial words and language and are able to socialize for longer periods of time when their interests are considered (R.L. Koegel, O'Dell, & Koegel, 1987; R.L. Koegel, Dyer, & Bell, 1987).
  2. Employing natural reinforcers - An early example of the importance of employing natural reinforcers was demonstrated when autistic children were observed in two different situations. In one situation, the children were taught to open the lid of a container in order to receive a reward inside; in the other situation, the children were taught to open the lid of an empty container and then given a food reward. In all cases, the children learned when the reward was direct and natural, inside the container (cf. F.L. Koegel & Williams, 1980).
  3. Rewarding communication attempts - Research indicates that children with severe communicative problems are able to produce correct speech more often and have a more positive affect when they are rewarded for their speech attempts (R.L. Koegel, O'Dell, & Dunlap, 1988).
  4. Practicing natural interactions - Consists of ongoing interactions between the teacher and the student; newer programs emphasize turn taking, as well as shared control over topic. Milieu teaching not only improves responsiveness, but disruptive and self-stimulatory behaviors tend to occur with a low frequency or not at all. This is in contrast to traditional intervention sessions where the children exhibited significantly higher levels of disruptive behaviors such as aggression and tantrums, etc. (R.L. Koegel, Koegel & Surratt, 1992).

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Communication and Language Intervention for Delayed Verbal Children

For those autistic children who utilize language to protest or to get desired items, clinicians are now implementing a series of self-initiated strategies. The following strategies will help to expand their communicative abilities:

  1. Teaching "What's That?"

The first question that children are taught is "What's that?", in order to increase their vocabularies of noun labels. Following this type of intervention, autistic children exhibit dramatic increases in vocabulary usage and more importantly they begin to ask "What's that?" In their natural environments such as at home with their families. To teach this question, items which the child likes (i.e. favorite food, or favorite toys) are placed in an opaque bag and then the child is prompted to ask, "What's that?". After the child asks this question, an item is removed from the bag, labeled and shown to the child. The child may then take the item which he/she desires. As the child begins to frequently ask, "What's that?", the child is prompted less. The next step is to prompt the child to repeat the name of his/her favorite item before showing it; when the child has mastered this, he/she is prompted less. At this point, the child should be asking "What's that?" And labeling the item quite frequently; when this occurs, new items are introduced which are neutral, in other words not desirable by the child. These neutral items along with the highly desired items are placed on a table, instead of in the bag. In the beginning, only one in four items is a neutral item with an unknown label. New items are gradually added until the child begins to ask "What's that?"in response to unknown items. A typical dialogue may be:

Child: "What's that?"

Adult: "It's a ring."

Child: "Ring."

Adult: "Yes, a ring."

  1. Teaching "Where?"

The second question which the clinicians taught was "Where is it?" In this intervention, the children's favorite items are hidden in specific locations such as in, on, under, on top, or behind. The child is then prompted to ask, "Where is it?" The adult then answers the question and tells the child where the item is; the child is then rewarded by being able to take the item from its location. After the child has mastered this question, he/she is prompted to repeat the preposition before being permitted to take the item. A typical dialogue:

Child: "Where is it?" Or "Where is pretzel?"

Adult: "Under the book."

Child: "Under" (Child looks under the book and takes the pretzel.)

Adult: "Right, the pretzel is under."

  1. Teaching "Whose?"

To teach children to ask this question, parents use a number of items which are clearly associated with a particular family member and then the child is prompted to ask, "Whose is it?" The adult provides the possessive form (i.e. "It's Mommy's") and then gives the item to the child. Gradually, the child learns by repeating the possessive form. Teaching "yours" and "mine" follows much the same pattern. A favorite item of the child is visible and the child is then prompted to ask, "Whose is it?". The adult answers, "It's yours." Yet, before the child is given the item, he/she is prompted to say "mine". Typically, autistic children have difficulty mastering the difference between mine and yours, but using a child's favorite item helps them to learn to use "mine" and "yours" appropriately. A typical dialogue:

Child: "Whose is it?"

Adult: "It's yours."

Child: "Mine." (Child takes item.)

  1. Teaching "What Happened?"

Preliminary research indicates that the following technique is very effective, especially with children who can use verbs in the present tense, but not in the past tense. To teach this question (past tense), pop-up books were utilized and each book was selected according to the child's interest. The adult pulls the tab on the book and prompts the child to ask "What happened?". The adult then describes what occurred and the child is prompted to repeat the past tense of the verb (i.e. "He ate ice cream.") A typical dialogue:

Adult: (Pulls tab so that a boy appeared to eat ice cream.)

Child: "What Happened?"

Adult: "He ate."

Child: "He ate."


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Social Behavior Characteristics and Interventions

Autistic children generally experience social difficulties due to their inappropriate behaviors (Dodge, 1983). Additionally, they tend to exhibit abnormal eye contact, inappropriate affect, hand movements, and body posture. For example, when autistic children played, they displayed less positive expressions than their typically developing peers (Yirmia, Kasari, Sigman, & Mundy, 1989). This difficulty in expressing appropriate emotions has also been noted in interactions between mothers and their autistic children; autistic children smiled less frequently in response to their mothers' smiles than typically developing children (Dawson, Hill, Spencer, Galpert, & Watson, 1990).

Before teaching autistic children socialization skills, it is important to consider which objects (i.e. toys, video games, etc.) Are popular among their peers. Gaylord-Ross et al. (1984) found that when popular objects were used that there were increases in both initiation and duration of interactions between autistic children and their peers. For example, they observed that even using chewing gum resulted in an increase in socialization. Additionally, increases in socialization were noted when autistic children were in contact with unfamiliar peers. The following interventions can help autistic children develop improved socialization skills:

  1. Eye Contact Intervention

An example: Prior to beginning this intervention, Ron, a 10 year old autistic child, was assessed in order to determine whether he would benefit from self-management. It was determined that this type of intervention would be beneficial, so treatment commenced. Ron never engaged in eye contact and needed to be prompted several times before responding to questions. By modeling the therapist, Ron was taught how to differentiate appropriate eye contact from inappropriate. Then, a reward system was implemented and when Ron showed good eye contact during conversation, he was permitted to listen to his Walkman. By the end of the first session, he was able to record the number of times in which he used good eye contact. He was then only rewarded for his accurate recording. During the next session, Ron was instructed to maintain good eye contact until he heard a watch's alarm chime. When the alarm chimed, he recorded whether he had been exhibiting good eye contact. Initially, the time he had to maintain good eye contact was for 10 sec. intervals and then gradually the time was increased to 2 min. intervals. Throughout the session, he was reinforced for independently recording his behavior. At each session, the intervals were increased, as well as the number of recordings necessary in order for him to listen to his Walkman. Eventually after much practice, Ron was taught how to self-manage at school. He would receive a new music cassette at the end of the week if he displayed good eye contact each day in school; his teachers and aides at school would then verify Ron's accuracy in recording his behavior. Like Ron, once an autistic child is taught to self-manage, he/she can then use this approach in any environment.

  1. Topic Shift Intervention

An example: Tarence, a 15 year-old, displayed difficulties in communicating with others, specifically, he did not discuss other people's topics for more than 1 or 2 minutes. Instead, he would continuously focus on the two subjects he enjoyed most. For Tarence to learn topic shift, he would first need to speak less in order to allow for a normal exchange. A program was implemented in which he was taught after a certain period of time to ask a question such as "Did you know that? "Has that happened to you?" or "What do you think?" When Tarence began the conversation and talked for a long period of time, he missed the cue signaling him to ask a question of the other person. However, he was able to communicate more effectively by starting with short intervals of talking and then gradually increasing his talking time. Next, Tarence was taught to paraphrase, in which he had to briefly state what the other person had said before saying what he wanted. This was difficult for Tarence because it required that he listen carefully to what his partner was saying. Through the modeling stage of self-management, Tarence was taught to summarize briefly such as "You like video games a lot." After he mastered this brief summary, he was prompted to comment a little more. This technique helped Tarence to give much more relevant responses to the other person's topics.

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Segregation vs. Integration

There is strong evidence that integrating children with developmental delays into an environment of similarly aged typical peers is very beneficial. Through integration, these children are able to effectively learn age-appropriate behaviors from their peers. Additionally, it appears that children who exhibit severe socialization problems can learn how to socialize better when they are exposed to a significant number of opportunities for appropriate social interactions (Guralnick & Groom, 1988; Stainback & Forest, 1989). For integration to be successful, autistic children must be able to act accordingly in many situations with a variety of people. One way to help autistic children with their behaviors is to teach them self-management. Self-management involves teaching the child to record the presence or absence of a certain behavior. A notebook with stickers can be used to keep track of his/her progress. Initially, the child is continuously given verbal praise along with material rewards for exhibiting particular behaviors. To ensure that these rewards are effective, it is important that the child help in selecting them. However, once the child has mastered self-management, reinforcement does not have to be constant and can then be gradually reduced. For further information on self-management, refer to the previous section, Teaching Children Self-Management and Independent Responding.

There are several advantages to integrating disabled children into the regular education system. First, they are able to form friendships with peers and practice how to effectively socialize. Second, when allowed to advance with the same peer group, disabled children are more likely to feel accepted and this acceptance can have a dramatic positive effect on social development (Asher & Dodge, 1986; Berndt, 1982; coie & Dodge, 1983; Coie, Lochman, Terry, & Hyman, 1992; Cowan, Pederson, Babigian, Izzo, & Trost, 1973; Hartup & Sancilio, 1986; Ollendick, Green, Francis, & Braum, 1991; Parker & Asher, 1987; Price & Dodge, 1989; robins, 1966; Roff, Sells, & Golden, 1972; Strayhorn & Strain, 1986). Additionally, a study conducted by Ollendick, Weist, Borden, and Green (1992) confirms that acceptance by peers is important for successful social development. These researchers followed 267 students for five years and found that those children who were rejected by their peers appeared to be significantly more at risk for long-term maladjustment problems. Since there is evidence that peer acceptance is a crucial factor in child development, then segregating disabled children from their typically developing peers would more than likely be detrimental to their development. Integrating disabled children into the regular classroom is not only beneficial to them , but research has indicated that typically developing children also benefit from having disabled children in the classroom (Biklen, Corrigan, & Quick, 1989; Peck, Donaldson, & Pezzoli, 1990).

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Peer Modeling

Research indicates that both teacher and peer-mediated interventions are effective in helping autistic children with their social behavior (Odom & Strain, 1986). Goldstein and colleagues (1992) taught preschool children to acknowledge and comment on the behavior of the autistic child and found that this technique helped to increase the social interactions between autistic children and their peers. Although this helped to increase interactions, Oke and Schreibman (1990) found that disruptive behavior did not decrease until the autistic child learned to initiate social interactions on his or her own. The following is an example of peer modeling: In order to have peers involved, Jenny's 6th grade teacher started a Thursday club for students to come and play games such as video or other planned activities during lunch. Based upon their interest in the club, three girls were given the opportunity to interact with Jenny and help her with fitting in. Jenny and her friends had private meetings with the teacher where they discussed the positive and negative aspects of their time together. They viewed their friendship with Jenny as important and each took on more responsibility without being prompted by the teacher or clinicians. This example shows that peers can help autistic children to fit in better, which in turn facilitates acceptance by peers, as well as friendships.

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Naturalistic Behavior Therapy

Most practitioners in the autism world have heard of the Lovaas technique of Applied Behavioral Analysis. This approach is based upon teaching the child skills through interaction in discrete trials in which the child is rewarded for the correct response. Rewards often include food, sometimes, unfortunately, foods to which the child may be allergic (M & M candies are frequently used!).

Studies from the Autism Research Center at the School of Education at the University of California at Santa Barbara, have shown that naturalistic behavior therapies are better than the applied behavioral analysis at changing autistic behaviors. This approach incorporates natural situations in which the child is already interacting and rewards the child through creating opportunities to do more of what the child already enjoys doing.

Non-autistic children may be recruited to be part of the therapeutic process. Examples of therapies in the classroom include a teacher developing a game for the entire class when her autistic student was obsessed with maps. The game consisted of the children dividing into teams and drawing states on sidewalks with chalk as fast as possible, including locating the capitol of the state. The autistic student was excellent at this game and was soon desired as a team member, thereby improving his opportunities for interaction with other children.

A book has been published about this approach, entitled Teaching Children with Autism. We are more excited about this method than the applied behavior analysis, though ABA as it is often called, has helped many children.

Other more permission therapies exist such as those offered by the Options Institute in Western Massachusetts, in which parents are helped to appreciate the special talents and uniqueness of the autistic child, and to learn to love the child as he or she actually is. These are often healing for families, especially when coupled with naturalistic behavior therapy and the other therapies mentioned here.

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