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Friday, January 31, 2014

Summarizing What We Know About Treatment

Volkmar et al. sum up the evidence in the Journal of the American Academy of Child & Adolescent Psychiatry
Structured educational and behavioral interventions have been shown to be effective for many children with ASD76 and are associated with better outcome.8 As summarized in the National Research Council report,76 the quality of the research literature in this area is variable, with most studies using group controls or single-subject experimental methods. In general, studies using more rigorous randomized group comparisons are sparse, reflecting difficulties in random assignment and control comparisons. Other problems include lack of attention to subject characterization, generalization of treatment effects, and fidelity of treatment implementation. Despite these problems, various comprehensive treatments approaches have been shown to have efficacy for groups of children, although none of the comprehensive treatment models has clearly emerged as superior.76
Behavioral interventions such as Applied Behavioral Analysis (ABA) are informed by basic and empirically supported learning principles.77 A widely disseminated comprehensive ABA program is Early Intensive Behavioral Intervention for young children, based on the work of Lovaas et al.78 Early Intensive Behavioral Intervention is intensive and highly individualized, with up to 40 hours per week of one-to-one direct teaching, initially using discrete trials to teach simple skills and progressing to more complex skills such as initiating verbal behavior. A meta-analysis found Early Intensive Behavioral Intervention effective for young children but stressed the need for more rigorous research to extend the findings.79 Behavioral techniques are particularly useful when maladaptive behaviors interfere with the provision of a comprehensive intervention program. In such situations, a functional analysis of the target behavior is performed, in which patterns of reinforcement are identified and then various behavioral techniques are used to promote a desired behavioral alternative. ABA techniques have been repeatedly shown to have efficacy for specific problem behaviors,80 and ABA has been found to be effective as applied to academic tasks,81[ut] adaptive living skills,82[ut] communication,83[ut] social skills,84[ut] and vocational skills.85[ct]Because most children with ASD tend to learn tasks in isolation, an explicit focus on generalization is important.86Communication

Communication is a major focus of intervention and typically will be addressed in the child's individualized educational plan in coordination with the speech-language pathologist. Children who do not yet use words can be helped through the use of alternative communication modalities, such as sign language, communication boards, visual supports, picture exchange, and other forms of augmentative communication. There is some evidence for the efficacy of the Picture Exchange Communication System, sign language, activity schedules, and voice output communication aids.87[rct],88, 89, 90 For individuals with fluent speech, the focus should be on pragmatic language skills training. Children and adolescents with fluent speech may, for example, be highly verbal but have severely impaired pragmatic language skills that can be addressed through explicit teaching. Many programs to enhance social reciprocity and pragmatic language skills are currently available (Table 2; see Reichow and Volkmar91 for an extensive review).92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103
There is consensus that children with ASD need a structured educational approach with explicit teaching.76 Programs shown to be effective typically involve planned, intensive, individualized intervention with an experienced, interdisciplinary team of providers, and family involvement to ensure generalization of skills. The educational plan should reflect an accurate assessment of the child's strengths and vulnerabilities, with an explicit description of services to be provided, goals and objectives, and procedures for monitoring effectiveness. Although the curricula used vary across programs, they often share goals of enhancing verbal and nonverbal communication, academic skills, and social, motor, and behavioral capabilities. In some instances, particularly for younger children, a parent-education and home component may be important. Development of an appropriate individualized educational plan is central in providing effective service to the child and family. Efficacy has been shown for 2 of the structured educational models, the Early Start Denver Model 104[rct] and the Treatment and Education of Autism and related Communication handicapped Children program,105[ct] but significant challenges remain in disseminating knowledge about effective interventions to educators.