Autism therapies

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Autism therapies
Opening a window to the autistic brain.jpg
A three-year-old with autism points to fish in an aquarium, as part of an experiment (2004) on the effect of intensive shared-attention training on language development. [1]

Autism therapies encompass educational and psychosocial interventions as well as medical management, all designed to improve communication, learning, adaptive skills of autistic people. Such methods of therapy seek to aid autistic people in dealing with difficulties and increase their functional independence. Treatment is typically catered to the person's needs. Training and support are also given to families of those diagnosed with autism. [2]

Contents

Available approaches include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy. [2] ABA is a behavioral therapy that aims to teach autistic children certain social and other behaviors by prompting using rewards and reinforcement learning through play, expressive labeling, and requesting as well as reduce aggressive and self-injurious behavior by assessing its environmental causes and reinforcing replacement behaviors. Occupational therapists work with autistic children by creating interventions that promote social interaction like sharing and cooperation. [3] They also support the autistic child by helping them work through a dilemma as the OT imitates the child and waiting for a response from the child. [3] For autistic adults, key treatment issues include residential care, job training and placement, sexuality, social skills, and estate planning. [4]

Studies of interventions have some methodological problems that prevent definitive conclusions about efficacy. [5] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the systematic reviews have reported that the quality of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options. [6] Intensive, sustained special education programs and behavior therapy early in life can help children with ASD acquire self-care, social, and job skills, [2] and often can improve functioning, and decrease severity of the signs and observed behaviors thought of as maladaptive; [7] Early, intensive ABA has demonstrated effectiveness, but many randomized clinical studies lacked adverse event monitoring, although such adverse effects may be common. [8] The limited research on the effectiveness of adult residential programs shows mixed results. [9]

Medical management addresses co-occurring challenges such as irritability, hyperactivity, anxiety, and sleep disturbances rather than core social and communication traits. Many such treatments have been prescribed off-label in order to target specific symptoms. [10] Antipsychotic medications such as risperidone and aripiprazole can reduce severe behavioral issues, while stimulants may help with attention and activity levels. [11] [12] Pharmacological treatments, including antidepressants and antipsychotics, may be prescribed to manage co-occurring conditions such as anxiety, depression, or irritability, but they do not treat the underlying characteristics of autism. [13] [14] Selective serotonin reuptake inhibitors, oxytocin, and other agents have shown inconsistent results. [15] [16] Parents of autistic children often encounter conflicting advice, unproven "miracle" treatments, and misleading claims in efforts to improve symptoms of a largely genetic disorder that currently has no cure. [17] [13] Many alternative or complementary treatments, including dietary restrictions, chelation, hyperbaric oxygen therapy, sensory integration, and acupuncture, lack scientific support and may pose health or financial risks. [18] [19]

Applied behavior analysis

Applied behavior analysis (ABA) is the applied research field of the science of behavior analysis, and it underpins a wide range of techniques used to treat autism and many other behaviors and diagnoses, [20] including those who are patients in rehab or in whom a behavior change is desired. ABA-based interventions focus on teaching tasks one-on-one using the behaviorist principles of stimulus, response and reward, [21] and on reliable measurement and objective evaluation of observed behavior. [2]

The use of technology has begun to be implemented in ABA therapy for the treatment of autism. [22] Robots, gamification, image processing, storyboards, augmented reality, and web systems have been shown to be useful in the treatment of autism. [22] These technologies are used to teach children with autism skill acquisition. [22] The web programs were designed to address skills such as attention, social behavior, communication, or reading. [22]

Criticisms and Considerations

While ABA is often described as a "gold standard" intervention for autism, it is not without criticism. Considered the most evidence-based and widely used intervention for autism, ABA has also been the subject of ethical debate. Some key considerations include:

Critics argue that ABA can, in some forms, overemphasize compliance or normalization rather than fostering autonomy and self-advocacy. [23] Recent scholarship emphasizes the importance of ensuring that ABA interventions respect individual dignity, focus on meaningful life outcomes, and are implemented with compassion and consent. [24]

Some autistic individuals and advocacy groups argue that ABA can be distressing and may contribute to PTSD symptoms, while others consider it an effective intervention for skill development. [26] [27] [28] [29] [30] [31] The Autistic Self Advocacy Network (ASAN) opposed the use of ABA, arguing that it encourages masking and compliance rather than supporting autistic identity. However, ABA remains a widely used intervention among clinicians and educators. [32] [33]

Some diagnosed with ASD or similar disorders advocate against behavioral therapies more broadly, like ABA and CBT, often as part of the autism rights movement, on the grounds that these approaches frequently reinforce the demand on autistic people to mask their neurodivergent characteristics or behaviors to favor a more 'neurotypical' and narrow conception of normality. [34] [35] [36] In the case of CBT and talking therapies, the effectiveness varies, with many reporting that they appeared 'too self-aware' to gain significant benefit, as the therapy was designed with neurotypical people in mind.  In autistic children, specifically, they also report that it is only mildly beneficial in aiding with their anxieties.

Early intensive behavioural intervention

Early intensive behavioural intervention (EIBI) is an intensive, ABA-based behavioural intervention for young children with autism spectrum disorder (ASD) and is one of the more commonly used treatments for ASD. [37] [38] Historically, EIBI developed from the UCLA Young Autism Project (often called the Lovaas model). [37] Common descriptions of EIBI emphasize three features: (1) structured teaching procedures such as discrete trial training; (2) a high staff-to-child ratio, often 1:1 early in treatment; and (3) delivery at high intensity (commonly about 20–40 hours per week) for extended periods (often one to four years) in home and/or school contexts. [37] [38] EIBI programs are typically overseen by practitioners trained in applied behaviour analysis and are often delivered using a structured curriculum or manual that specifies targets and teaching sequences. [37]

EIBI is sometimes conflated with ABA. ABA refers to the broader science and set of principles underlying behaviour change, whereas EIBI is one intervention model that applies ABA methods in an intensive, comprehensive format; ABA therefore encompasses far more than EIBI alone. [37]

Clinical guidance generally supports starting behavioural supports as early as possible for children with ASD, including during the diagnostic process when appropriate. [38] Because ASD presentations and support needs vary widely, management is individualized and there is no single approach that is universally recommended for all children. [38] [37]

Across guidance documents, comprehensive intervention programs are often described as including elements such as: targeting core social-communication and related developmental skills; providing teaching in structured and predictable contexts; maintaining low student-to-teacher ratios; planning for generalization and maintenance; involving families; using functional approaches to challenging behaviour; and tracking progress over time to guide adjustments. [37]

In EIBI, the core deficits of ASD are addressed through individualized intervention programs tailored to the child’s current skills such as communication and social skills. These plans use behavioral techniques to teach new skills. A function-based approach is also used to reduce challenging behaviors that interfere with learning and to teach more appropriate replacement behaviors. [37] EIBI remains one of the most requested comprehensive treatment models for ASD. [37] Because EIBI continues to evolve over time, the evidence base needs to be updated periodically. [37]

As stated by the Canadian Paediatric Society: "Behavioural interventions have emerged as the main evidence-based treatment for children with ASD." Behavioural interventions are typically grounded in ABA learning principles and implemented across different settings to teach skills and reduce learning-interfering behaviours. [38] EIBI is one example within this broader category and is commonly delivered with structured supervision and a planned scope-and-sequence of teaching targets. [37]

Early intensive behavioural interventions are often used with preschool-aged children (about 2–5 years old), and studies report some improvement evidence in adaptive functioning, IQ, and receptive and expressive language, although findings are variable across children and studies. [38] In the United States, behavioural approaches—including EIBI—are among the most commonly recommended interventions. By comparison, Project AIM reported that NICE guidance in England has tended to prioritize lower-intensity social-communication interventions (such as PACT and JASPER) rather than recommending intensive behavioural programs as routine care. [39]

Evidence base and limitations

For EIBI specifically, the 2018 Cochrane review rated the certainty of evidence for key outcomes as low to very low using GRADE criteria. [37] Separately, Project AIM reported that the overall early-childhood autism intervention literature expanded substantially by 2021; across intervention types, effects differed by outcome domain and intervention category, and results were mixed rather than uniform. [39] The updated Project AIM review included 252 studies, including 173 randomized controlled trials, and concluded that RCT evidence supports the effectiveness of some specific early-childhood interventions for some outcomes, with considerable variation across outcomes and approaches. [39] A 2022 synthesis focusing on routine clinical care concluded that early behavioural interventions with established efficacy can produce beneficial effects in real-world services, while also emphasizing ongoing needs such as clearer program classification, more consistent outcome measurement, and stronger controlled follow-up designs. [40]

Professional guidance describes EIBI as a comprehensive treatment model for young children, typically delivered as a comprehensive ABA program, and often discussed alongside other comprehensive approaches such as TEACCH and the Early Start Denver Model (ESDM). [41]

Discrete trial training

Discrete trial training (DTT) is an applied behavior analysis teaching method developed by Ivar Lovaas at UCLA that breaks skills into small, repeatable steps taught with prompts, modeling and positive reinforcement. It is often used as part of early intensive behavioral intervention (EIBI) for autistic children. [37]

Pivotal response training

Pivotal response treatment (PRT) is a naturalistic intervention derived from ABA principles. Instead of individual behaviors, it targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations; it aims for widespread improvements in areas that are not specifically targeted. The child determines activities and objects that will be used in a PRT exchange. Intended attempts at the target behavior are rewarded with a natural reinforcer: for example, if a child attempts a request for a stuffed animal, the child receives the animal, not a piece of candy or other unrelated reinforcer. [42]

Early Start Denver Model (ESDM)

Early Start Denver Model (ESDM) is a subtype of applied behavior analysis (ABA) designed for autistic toddlers and preschoolers, typically between 12 and 48 months of age. [43] Developed in the 1980s by psychologists Sally J. Rogers and Geraldine Dawson, the model integrates behavioral, developmental, and relationship-based approaches to promote early learning. [44] It emphasizes natural play routines, joint attention, and parent participation to build language, social interaction, imitation, and cognitive skills. [45]

Research, including randomized controlled trials and meta-analyses, has found that ESDM can improve cognitive and language development and may reduce autism symptoms over time. [46] [47] The model is recognized internationally, including by the Centers for Disease Control and Prevention in the United States, [48] the National Disability Insurance Scheme in Australia, [49] and health authorities in France and Brazil. [50] [51]

Educational interventions

Educational interventions attempt to help children not only to learn academic subjects and gain traditional readiness skills, but also to improve functional communication and spontaneity, enhance social skills such as joint attention, develop cognitive skills such as symbolic play, reduce disruptive behavior, and generalize learned skills by applying them to new situations. Several program models have been developed, which in practice often overlap and share many features, including: [2]

Several educational intervention methods are available, as discussed below. They can take place at home, at school, or at a center devoted to autism treatment; they can be implemented by parents, teachers, speech and language therapists, and occupational therapists. [2] [3] A 2007 study found that augmenting a center-based program with weekly home visits by a special education teacher improved cognitive development and behavior. [53]

Many intervention studies have methodological limitations, such as small sample sizes and inconsistent outcome measures, making it difficult to draw definitive conclusions about efficacy. [5] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options. [6] Concerns about outcome measures, such as their inconsistent use, most greatly affect how the results of scientific studies are interpreted. [54] A 2009 Minnesota study found that parents follow behavioral treatment recommendations significantly less often than they follow medical recommendations, and that they adhere more often to reinforcement than to punishment recommendations. [55] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills, [2] and often improve functioning and decrease symptom severity and maladaptive behaviors; [7] claims that intervention by around age three years is crucial are not substantiated. [56] Mind-body therapies are frequently utilized by autistic individuals. However, there remains a lack of comprehensive examination into the specific types of mind-body therapies used for ASD and their intended outcomes. [57]

SCERTS

The SCERTS model [58] is an educational model for working with children with ASD. It was designed to help families, educators, and therapists work cooperatively together to maximize progress in supporting the child.

The acronym refers to the focus on:

National education policies

U.S.

In the United States, there have been three major policies addressing special education in the United States. These policies were the Education for All Handicapped Children Act in 1975, the Individuals with Disabilities Education Act in 1997, and the No Child Left Behind in 2001. The development of those policies showed increased guidelines for special education and requirements; such as requiring states to fund special education, equality of opportunities, help with transitions after secondary schooling, requiring extra qualifications for special education teachers, and creating a more specific class setting for those with disabilities. [59] [60] [61] The Individuals with Disabilities Education Act, specifically had a large impact on special education as public schools were then required to employ high qualified staff. In 2009, for one to be a Certified Autism Specialist the requirements included: a master's degree, two years of career experience working with the autism population, earn 14 continuing education hours in autism every two years, and register with the International Institute of Education. [62]

Perceived disadvantages of autistic people in the U.S. in the 2010s

Martha Nussbaum discusses how education is one of the fertile functions that is important for the development of a person and their ability to achieve a multitude of other capabilities within society. [63] Autism can present challenges in traditional educational environments, particularly in areas such as imitation, observational learning, and communication. As of 2014, of all disabilities affecting the population, autism ranked third lowest in acceptance into a postsecondary education institution. [64] In a 2012 study funded by the National Institute of Health, Shattuck et al. found that only 35% of autistics are enrolled in a 2 or 4 year college within the first two years after leaving high school compared to 40% of children who have a learning disability. [65] Due to the growing need for a college education to obtain a job, this statistic shows how autistics are at a disadvantage in gaining many of the capabilities that Nussbaum discusses and makes education more than just a type of therapy for those with autism. [64] According to the 2012 study by Shattuck, only 55% of children with autism participated in any paid employment within the first two years after high school. Furthermore, those with autism that come from low income families tend to have lower success in postsecondary schooling. [65]

Oftentimes, schools lacked the resources to create (what at the time was considered) an optimal classroom setting for those 'in need of special education'. In 2014 in the United States, it could cost between $6,595 to $10,421 extra to educate a child with autism. [66] In the 2011–2012 school year, the average cost of education for a public school student was $12,401. In some 2015 cases, the extra cost required to educate a child with autism nearly doubled the average cost to educate the average public school student. [67] As the abilities of autistic people vary highly, it is highly challenging to create a standardized curriculum that will fit all autistic learning needs. In the United States, in 2014 many school districts required schools to meet the needs of disabled students, regardless of the number of children with disabilities there are in the school. [68] This combined with a shortage of licensed special education teachers has created a deficiency in the special education system. In 2011 the shortage caused some states to give temporary special education licenses to teachers with the caveat that they receive a license within a few years. [69]

Mexico

In 1993, Mexico passed an education law that called for the inclusion of those with disabilities. This law was very important for Mexico education, however, there have been issues in implementing it due to a lack of resources. [70]

United Nations and internationally

There have also been multiple international groups that have issued reports addressing issues in special education. The United Nations on "International Norms and Standards relating to Disability" in 1998. This report cites multiple conventions, statements, declarations, and other reports such as: The Universal Declaration of Human Rights, The Salamanca Statement, the Sundberg Declaration, the Copenhagen Declaration and Programme of Action, and many others. One main point that the report emphasizes is the necessity for education to be a human right. The report also states that the "quality of education should be equal to that of persons without disabilities." The other main points brought up by the report discuss integrated education, special education classes as supplementary, teacher training, and equality for vocational education. [71] The United Nations also releases a report by the Special Rapporteur that has a focus on persons with disabilities. In 2015, a report titled "Report of the Special Rapporteur to the 52nd Session of the Commission for Social Development: Note by the Secretary-General on Monitoring of the implementation of the Standard Rules on the Equalization of Opportunities for Persons with Disabilities" was released. This report focused on looking at how the many countries involved, with a focus on Africa, have handled policy regarding persons with disabilities. In this discussion, the author also focuses on the importance of education for persons with disabilities as well as policies that could help improve the education system such as a move towards a more inclusive approach. [72] The World Health Organization has also published a report addressing people with disabilities and within this there is a discussion on education in their "World Report on Disability" in 2011. [73] Other organizations that have issued reports discussing the topic are UNESCO, UNICEF, and the World Bank. [74]

Communication interventions

The inability to communicate, verbally or nonverbally, is a core deficit in autism. Children with autism are often engaged in repetitive activity or other behaviors because they cannot convey their intent any other way. They do not know how to communicate their ideas to caregivers or others. Helping a child with autism learn to communicate their needs and ideas is absolutely core to any intervention. Communication can either be verbal or nonverbal. Some autistic children benefit from intensive interventions to develop communication skills.

Communication interventions fall into two major categories. First, many autistic children do not speak, or have little speech, or have difficulties in effective use of language. [75] Social skills have been shown to be effective in treating children with autism. [75] Interventions that attempt to improve communication are commonly conducted by speech and language therapists, and work on joint attention, communicative intent, and augmentative and alternative communication (AAC) methods such as visual methods, [76] for example visual schedules. AAC methods do not appear to impede speech and may result in modest gains. [77] A 2006 study reported benefits both for joint attention intervention and for symbolic play intervention, [78] and a 2007 study found that joint attention intervention is more likely than symbolic play intervention to cause children to engage later in shared interactions. [79]

Second, social skills treatment attempts to increase social and communicative skills of autistic individuals, addressing a core deficit of autism. A wide range of intervention approaches is available, including modeling and reinforcement, adult and peer mediation strategies, peer tutoring, social games and stories, self-management, pivotal response therapy, video modeling, direct instruction, visual cuing, Circle of Friends and social-skills groups. [80] A 2007 meta-analysis of 55 studies of school-based social skills intervention found that they were minimally effective for children and adolescents with ASD, [81] and a 2007 review found that social skills training has minimal empirical support for children with Asperger syndrome or high-functioning autism. [82]

Parent-mediated interventions

Parent-mediated interventions offer support and practical advice to parents of autistic children. [76] A 2013 Cochrane Review found that there was no evidence of gains in most of the primary measures of the studies (e.g., the child's adaptive behavior), however there was strong evidence for a positive pattern of change in parent-child interactions. There was some uncertain evidence of changes in the child's language and communication. [83] A very small number of randomized and controlled studies suggest that parent training can lead to reduced maternal depression, improved maternal knowledge of autism and communication style, and improved child communicative behavior, but due to the design and number of studies available, definitive evidence of effectiveness is not available. [84]

Early detection of ASD in children can often occur before a child reaches the age of three years old. Methods that target early behavior can influence the quality of life for a child with ASD. Parents can learn methods of interaction and behavior management to best assist their child's development. A 2013 Cochrance review concluded that there were some improvements when parent intervention was used. [83]

TEACCH

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH), which has come to be called "structured teaching", emphasises structure by using organized physical environments, predictably sequenced activities, visual schedules and visually structured activities, and structured work/activity systems where each child can practice various tasks. [2] Parents are taught to implement the treatment at home. A 1998 controlled trial found that children treated with a TEACCH-based home program improved significantly more than a control group. [85] A 2013 meta-analysis compiling all the clinical trials of TEACCH indicated that it has small or no effects on perceptual, motor, verbal, cognitive, and motor functioning, communication skills, and activities of daily living. There were positive effects in social and maladaptive behavior, but these required further replication due to the methodological limitations of the pool of studies analysed. [86]

Medical management

Medication

Many medications are used to treat problems associated with ASD. [87] More than half of U.S. children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics. [88]

Research has focused on atypical antipsychotics, especially risperidone, which has the largest amount of evidence that consistently shows improvements in irritability, self-injury, aggression, and tantrums associated with ASD. [89] Risperidone is approved by the Food and Drug Administration (FDA) for treating symptomatic irritability in autistic children and adolescents. [90] In short-term trials (up to six months) most adverse events were mild to moderate, with weight gain, drowsiness, and high blood sugar requiring monitoring; long term efficacy and safety have not been fully determined. [91] It is unclear whether risperidone improves autism's core social and communication deficits. [90] The FDA's decision was based in part on a study of autistic children with severe and enduring problems of tantrums, aggression, and self-injury; risperidone is not recommended for autistic children with mild aggression and explosive behavior without an enduring pattern. [92]

No intervention perspective

Some autism self-advocacy organizations view autism as a different neurology rather than a mental disorder and advocate for acceptance over intervention. However, other advocacy groups, parents, and medical professionals continue to explore treatments aimed at addressing autism-related challenges. [32] [33] [93] [94]

Criticisms of most educational, social, and behavioral focused autism therapies as put forth by autistic adults, teachers, and researchers frequently fall into the idea of these programs encouraging [95] or even training behavioral responses directed toward "camouflaging", [96] [97] [98] [99] [100] [101] [102] [103] "passing as non-autistic", [95] [104] [105] or "masking". [96] [103] [106] [107] [108] [109] [110] [101] [111] Recent studies indicate that, among autistic people, burnout and mental health difficulties associated with masking [112] [113] "driven by the stress of masking and living in an unaccommodating neurotypical world" [114] [115] is an issue (which also impacts autistic young people [116] and children). [117] Animal-assisted therapy used to be directed toward symptoms of autism and some studies of the programs are now directed toward burnout. [118]

In 2018 more studies began involving the experiences of autistic adults [119] [120] including their experiences with general practice medicine. [121] Subsequent related studies have focused on communication preferences of autistic adults [122] and the idea of "the 'Autistic Advantage', a strengths-based model". [123] [124] [125]

See also

References

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