Can Social Skills and Behavior Be Improved?
A number of treatment approaches have evolved in the decades since
autism was first identified. Some therapeutic programs focus on
developing skills and replacing dysfunctional behaviors with more
appropriate ones. Others focus on creating a stimulating learning
environment tailored to the unique needs of children with autism.
Researchers have begun to identify factors that make certain treatment
programs more effective in reducing- or reversing-the limitations imposed
by autism. Treatment programs that build on the child's interests, offer
a predictable schedule, teach tasks as a series of simple steps, actively
engage the child's attention in highly structured activities, and provide
regular reinforcement of behavior, seem to produce the greatest gains.
Parent involvement has also emerged as a major factor in treatment
success. Parents work with teachers and therapists to identify the behaviors
to be changed and the skills to be taught. Recognizing that parents
are the child's earliest teachers, more programs are beginning to train
parents to continue the therapy at home. Research is beginning to suggest
that mothers and fathers who are trained to work with their child can
be as effective as professional teachers and therapists.
Professionals have found that many children with autism learn best
in an environment that builds on their skills and interests while
accommodating their special needs. Programs employing a developmental
approach provide consistency and structure along with appropriate
levels of stimulation. For example, a predictable schedule of
activities each day helps children with autism plan and organize
their experiences. Using a certain area of the classroom for each
activity helps students know what they are expected to do. For
those with sensory problems, activities that sensitize or desensitize
the child to certain kinds of stimulation may be especially helpful.
In one developmental preschool classroom, a typical session starts
with a physical activity to help develop balance, coordination, and
body awareness. Children string beads, piece puzzles together, paint
and participate in other structured activities. At snack time, the teacher
encourages social interaction and models how to use language to ask
for more juice. Later, the teacher stimulates creative play by prompting
the children to pretend being a train. As in any classroom, the children
learn by doing.
Although higher-functioning children may be able to handle academic
work, they too need help to organize the task and avoid distractions.
A student with autism might be assigned the same addition problems as
her classmates. But instead of assigning several pages in the textbook,
the teacher might give her one page at a time or make a list of specific
tasks to be checked off as each is done.
When people are rewarded for a certain behavior, they are more likely
to repeat or continue that behavior. Behaviorist training approaches
are based on this principle. When children with autism are rewarded
each time they attempt or perform a new skill, they are likely
to perform it more often. With enough practice, they eventually
acquire the skill. For example, a child who is rewarded whenever
she looks at the therapist may gradually learn to make eye contact
on her own.
Dr. O. Ivar Lovaas pioneered the use of behaviorist methods for children
with autism more than 25 years ago. His methods involve time-intensive,
highly structured, repetitive sequences in which a child is given a
command and rewarded each time he responds correctly. For example, in
teaching a young boy to sit still, a therapist might place him in front
of chair and tell him to sit. If the child doesn't respond, the therapist
nudges him into the chair. Once seated, the child is immediately rewarded
in some way. A reward might be a bit of chocolate, a sip of juice, a
hug, or applause-whatever the child enjoys. The process is repeated
many times over a period of up to two hours. Eventually, the child begins
to respond without being nudged and sits for longer periods of time.
Learning to sit still and follow directions then provides a foundation
for learning more complex behaviors. Using this approach for up to 40
hours a week, some children may be brought to the point of near-normal
behavior. Others are much less responsive to the treatment.
However, some researchers and therapists believe that less intensive
treatments, particularly those begun early in a child's life, may be
more efficient and just as effective.
So, over the years, researchers sponsored by NIMH and other agencies
have continued to study and modify the behaviorist approach. Today,
some of these behaviorist treatment programs are more individualized
and built around the child's own interests and capabilities. Many programs
also involve parents or other non-autistic children in teaching the
child. Instruction is no longer limited to a controlled environment,
but takes place in natural, everyday settings. Thus, a trip to the supermarket
may be an opportunity to practice using words for size and shape. Although
rewarding desired behavior is still a key element, the rewards are varied
and appropriate to the situation. A child who makes eye contact may
be rewarded with a smile, rather than candy. NIMH is funding several
types of behaviorist treatment approaches to help determine the best
time for treatment to start, the optimum treatment intensity and duration,
and the most effective methods to reach both high- and low-functioning
In trying to do everything possible to help their children, many parents
are quick to try new treatments. Some treatments are developed
by reputable therapists or by parents of a child with autism,
yet when tested scientifically, cannot be proven to help. Before
spending time and money and possibly slowing their child's progress,
the family should talk with experts and evaluate the findings
of objective reviewers. Following are some of the approaches that
have not been shown to be effective in treating the
majority of children with autism:
- Facilitated Communication, which assumes that by supporting a nonverbal
child's arms and fingers so that he can type on a keyboard, the child
will be able to type out his inner thoughts. Several scientific studies
have shown that the typed messages actually reflect the thoughts of
the person providing the support.
- Holding Therapy, in which the parent hugs the child for long periods
of time, even if the child resists. Those who use this technique contend
that it forges a bond between the parent and child. Some claim that
it helps stimulate parts of the brain as the child senses the boundaries
of her own body. There is no scientific evidence, however, to support
- Auditory Integration Training, in which the child listens to a variety
of sounds with the goal of improving language comprehension. Advocates
of this method suggest that it helps people with autism receive more
balanced sensory input from their environment. When tested using scientific
procedures, the method was shown to be no more effective than listening
- Dolman/Delcato Method, in which people are made to crawl and move
as they did at each stage of early development, in an attempt to learn
missing skills. Again, no scientific studies support the effectiveness
of the method.
It is critical that parents obtain reliable, objective information
before enrolling their child in any treatment program. Programs that
are not based on sound principles and tested through solid research
can do more harm than good. They may frustrate the child and cause the
family to lose money, time, and hope.
Selecting a treatment program
Parents are often disappointed to learn that there is no single best treatment
for all children with autism; possibly not even for a specific child.
Even after a child has been thoroughly tested and formally diagnosed,
there is no clear "right" course of action. The diagnostic team may
suggest treatment methods and service providers, but ultimately it is
up to the parents to consider their child's unique needs, research the
various options, and decide.
Above all, parents should consider their own sense of what will work
for their child. Keeping in mind that autism takes many forms, parents
need to consider whether a specific program has helped children like
Exploring Treatment Options Parents may find these questions helpful
as they consider various treatment programs:
- How successful has the program been for other children?
- How many children have gone on to placement in a regular school
and how have they performed?
- Do staff members have training and experience in working with children
and adolescents with autism?
- How are activities planned and organized?
- Are there predictable daily schedules and routines?
- How much individual attention will my child receive?
- How is progress measured? Will my child's behavior be closely observed
- Will my child be given tasks and rewards that are personally motivating?
- Is the environment designed to minimize distractions?
- Will the program prepare me to continue the therapy at home?
- What is the cost, time commitment, and location of the program?
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