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Roberta Marando

As of today, a treatment of choice for Autism has not yet been identified. However, many researches show that an early and intensive programme involving parents, including teaching of basic skills and involving the opportunity of integrating with other children, can result in significant improvements (Jordan, Jones 1999). There are many treatments available today: this article is not aimed at introducing these one by one, but rather at illustrating some of the best known approaches, which are regarded as most effective.

TEACCH - Treatment and Education of autistic and Related Communication Handicapped Children

TEACCH is fundamentally a State-based organisation providing services, created by Prof. Eric Schopler and his partners in the State of North Carolina - USA, in the ‘60s.

Assumptions and Guidelines

Autism is regarded to be a multiple-aetiology developmental disorder, whose effects last for life. Based on this assumption, seven principles have been identified (Schopler, 1994).
1. Improve adjustment to the environment for every person with autism. This principle can be achieved through two complementary strategies: on one side by increasing individual skills, and on the other by adjusting the environment to meet the deficiencies. Both elements are essential.
2. Parents are regarded as co-therapists: they work together with the experts to ensure that the techniques adopted can be continued at home.
3. The functional assessment of a child’s skills is an indispensable phase for setting up a personalised treatment.
To this end, the TEACCH Division has prepared specific tests, such as the PEP-R test (Psychoeducational Profile Revised) (Schopler et al., 1990) which allows both an evaluation of the child’s skills in seven different areas, and detection of any deviant behaviours.
The AAPEP (Adolescent and Adult Psychoeducational Profile) test (Mesibov et al. 1988) is a tool that allows evaluation of teenagers and adults with the purpose of identifying educational requirements for successfully obtaining a job and planning one’s life.
4. Teaching is based on structured education, which is a strategy based on the needs, the skills and the deficiencies of people with autism. It is a system for organising educational environments, developing appropriate activities and helping students understand what is expected of them. Stress is placed on visual components (since visual processing is a strength for people with autism, which minimises the hearing processing deficits) and on the importance of routine.
5. The fifth principle stresses the importance of strengthening the children’s skills, whilst acknowledging their weaknesses. Indeed, when a formalised assessment is carried out it is possible to identify acquired skills, emerging skills (that is the skills which the child does not master yet but is in the process of acquiring) and those which are not yet available. A good educational programme must be based on the existing skills in order to allow the emerging skills to develop. Teaching of not yet existing skills must be postponed.
6. Educational procedures are based on cognitive and behavioural theories.
7. The seventh principle refers to the training and qualification of professionals who are to work with people with autism; this training has to be of a multidisciplinary nature. Therefore professionals must be in a position to understand the full range of problems related to autism.

Objectives

The objective the TEACCH programme aims at is to develop the skills which enable an individual to lead the most independent life possible and to take part as much as possible in community life.

Parents’ Role

Parents play a crucial role, in that they are the ones who know their children best; they therefore take part in the setting up of the objectives for the therapeutic programme, and help their children generalise in the home and in the community environment the skills their child has learnt.

Effectiveness Studies

Studies have been published both on the specific components of the programme, and on the satisfaction of the parents involved.
As regards the first typology, a study by Schopler et al. (1971) has demonstrated the greater effectiveness of structured education compared to the non-structured type. This result was further confirmed by a subsequent research (Bartak, Rutter, 1973), by varying the structure degree in a teaching programme for autistic students. As regards the second typology, a 1981 study (Schopler et al.) has shown that a community-based programme, such as TEACCH, can significantly reduce the need for institutionalising adults with autism.

ABA Applied Behavioural Analysis

The term ABA relates to the most widely known behavioural approach within education of people with autism. One of the best known behavioural techniques is the “Lovaas” method1 , which is named after its inventor Ivar Lovaas, Psychology Professor at Los Angeles University, in California.
The Lovaas method is an early and intensive behavioural therapy, based on over thirty years of clinic experience.

Assumptions and Guidelines

Autism is regarded as a syndrome comprising specific behavioural extremes and deficiencies. The extremes are the behaviours taking place with an inappropriate intensity and frequency or behaviours which are inappropriate in themselves. Behavioural deficiencies are behaviours which are not implemented with the required strength or which are not displayed and whose absence is abnormal. Furthermore, all behavioural strategies are based on the principle that pleasant consequences may encourage a good behaviour, whilst unpleasant consequences, such as punishments, may assist in controlling unacceptable behaviours. The method requires thirty to forty hours a week of individual therapy with adequately trained operators. The teaching of all skills takes place in a structured manner, after having broken down the single general objective into small reachable steps.

Objectives

The method is aimed, starting from teaching basic skills such as sitting down and complying with simple requests, at developing speech, increasing social behaviours, promoting cooperative games and reducing the number of rituals, outbursts of rage and aggressive behaviours.

Parents’ Role

Parents’ involvement is regarded as crucial in order to reach such objectives.

Effectiveness Studies

Lovaas (1987) has reported the results of his work in a study which has shown that 47% of children who had followed the 40 hour per week programme, for 50 weeks, had subsequently successfully started school. In 1993, a follow-up study confirmed the results in time (McEachin S.J. et al.).

PECS: Picture Exchange Communication System

This method, which was developed by Lori Frost and Andrew Bondy, was designed as part of a national USA school programme (Delaware Autistic Program), as a means to help autistic children to communicate. As the name itself infers, this system is based on picture exchange to foster communication.
The method was subsequently modified and broadened and it is now also used with adults and with other communication disorders.

Assumptions and Guidelines

The first communicative function to be taught to people with autism is that of requesting something, in that, unlike others, it involves a type of psychological reinforcement which autistic people are sensitive to (Bondy et. al 1989). Indeed, obtaining the desired object represents in itself a tangible reward which stimulates the person to repeat the requesting behaviour.
The teaching of other communication functions based on labelling does not prove as effective, in that it requests reinforcements of a social nature, which initially may not represent a sufficiently strong motivation. The method provides for six learning stages (Frost, Bondy 1994), following a first stage during which family members and teachers select the articles that the autistic person looks for and takes most often:
1. In the first stage the child is to learn to take one single picture and place it in the open hand of the teacher in order to swap it with the desired object, which is placed in a position that is visible but nor reachable. In this phase, no verbal suggestions are used, so as not to create a dependence on such, but only physical and gesture suggestions are used.
2. In the second stage, the child learns to move towards the teachers, who will be at some distance from him, to deliver the picture he has picked up
3. In the third stage, the child is taught to ask for the requested object by selecting the related picture from a number of different pictures.
4. In the fourth stage, the child learns to put together a request “sentence” through the picture corresponding to the words “I want” and that of the desired object and to deliver the strip on which he has placed the two pictures to the person with whom he wishes to communicate.
5. In the fifth stage, the child learns to reply to the question “What do you want?”
6. In the sixth stage, the child in taught to reply to the questions “What do you see?” and “What do you have?”. Subsequently, new concepts and communicative functions are taught.

Objectives

This method is aimed at quickly teaching to children and adults with autism functional communication abilities.

Parents’ Role

Parents are encouraged to use this method in every situation in which the child wishes to communicate.

Effectiveness Studies

Studies carried out (Bondy, Frost, 1994) have shown improvements both in children’s communicative abilities and in speach development.

PHARMACHOLOGICAL TREATMENT

Paul Gringras (2000) stresses that two different approaches can be identified in the use of psychotropic drugs with autistic people.
The first one is aimed at working on specific symptoms, such as for instance hyperactivity and aggressiveness; the second one is aimed at working on the core of autism-related alterations.

Assumptions and Guidelines

As regards the first approach, the basic assumption is that “no drug can correct the altered brain structures or nervous connections which appear to underlie autism” (NIM, 1997). The use of drugs is aimed at addressing various types of symptoms which may be associated with autism, such as hyperactivity, compulsiveness, rituality, sleeping problems, self-injurious behaviours and aggressiveness. Such symptoms do not only negatively affect the person’s life, but may also represent a source of distress for the family and for those who take care of the person. Furthermore, they can hinder the acquisition of new abilities. (Gringras, 2000). Nevertheless, several authors stress that the pharmacologic approach cannot be regarded as an alternative to other educational tools (Gringras, 2000; Masi et. al 1999; Mc Dougle, 1997).
An overview of drugs currently used in Pervasive Developmental Disorders can be found in Masi et. al (1999). As regards the second approach, drugs are regarded as the means to act on the crucial symptoms of autism in the areas of social interaction, of speech and of restricted or repetitive behaviours. According to Gringras (2000), examples of drugs belonging to this category are naltrexone, phenfluramine and secretine. In all three cases great sensation was caused by the idea that a cure for autism may be found. The hypotheses underlying their success differs, ranging from the theory according to which there is an excess of opioid activity in the brain (naltrexone), to the reduction of serotonin levels (phenfluramine). Furthermore, we ought to keep in mind that, before starting a pharmacological treatment, one needs to carefully assess the risk/benefit ratio, in view of the side effects involved.

Objectives

The use of drugs in people with autism is aimed at controlling behaviours which may negatively affect their quality of life, once specific educational programmes have proved unsuccessful.

Parents’ Role

In literature there is no particular reference to the major role plaid by parents when one’s child starts a pharmacological treatment. I am referring, for instance, to the need to monitor the intensity and frequency of the symptom thorough specially designed control sheets, before, during and after drug administration.

Effectiveness Studies

With reference to the first approach, Masi, Marcheschi and Pfanner (1999) emphasise that the drugs which are currently employed prove effective in some subjects and not in others, and that they can occasionally even worsen the situation. The great heterogeneity of people that can be found within the autistic spectrum is thought to be the cause for differing reactions to drugs. As regards the second approach, the studies that have been carried out have provided evidence that phenfluramine and naltrexone have no effect on the crucial symptoms of autism (Mc Dougle, 1997).
As regards secretine, a “double-blind” trial (Sandler et. al, 1999) has not only ascertained the absence of differences between the experimental group and the control group after a single injection of secretine, but has also shown that both in the group in which secretine was administered and in the placebo group there was a substantial reduction in the severity of symptoms in time. It is therefore quite obvious that double blind trial studies are essential in order to evaluate the effectiveness of a drug (Gringas, 2000; Grandin, 1998).

NON-CONVENTIONAL APPROACHES

This category includes certain treatments which, when subject to serious effectiveness studies, have not proved able to assist people with autism, such as for instance the Facilitated Communication and the Delacato Method (NIH). I will only briefly touch on the Facilitated Communication method, in view of its technical diffusion and of the sensation caused.

Facilitated Communication

Facilitated Communication (FC) is a method which was first devised in Australia, during the ‘70s, thanks to the work accomplished by Rosemary Crossley (Crossley, McDonald 1980), as a means for helping children with physical and/or mental disabilities to communicate; its use was subsequently extended to people with autism. Douglas Bliken, who was the first to introduce the FC technique and its applications among people with autism in the USA, states that “the communication difficulty appears to be of a practical rather than cognitive nature” (Biklen 1993 page 13). The use of FC with autistic people is therefore based on the assumption that many of the existing difficulties are due to movement disabilities (Attwood 1993, Hill, Leary 1993) rather than to social or communicative deficiencies. FC takes place by typing letters on a keyboard and involves the presence of a “facilitator” supplying a support (which is both physical and emotional) and who initially supports the hand or arm of the person. Many studies have been carried out on this method, showing that the message produced reflects in fact the thoughts of the facilitator (e.g.: Crews et. al, 1995; Regal et. al, 1994; Smith et. al, 1994; Wheeler et. al, 1993).

CONCLUSIONS

When a family receives a diagnosis of autism for a child, often a long research starts in order to find the best course of action to be pursued. It may not prove easy to make a choice among the enormous variety of treatments existing today. It is therefore essential on one side to put together as much information as possible and, on the other, to approach specialists, so as to find one’s way towards methods based on serious scientific researches, which have been subject to effectiveness studies. Furthermore, it is important not to waste time, since one fact on which the whole scientific community agrees today is the need for an early intervention with a good educational programme. Translated by interpres sas

Roberta Marando
Service Manager of the Centre For Diagnosis and Treatments- Children and Autism Foundation (Italy)

1 This method is also know under the following names: · Prof. Lovaas’ UCLA (University of Los Angeles) Program · Home Based Behavioural Intervention · UCLA model for applied behavioural analysis