Based on many researches, surveys, and studies conducted recently, the early intensive intervention method showed a significant outcome for children having autism. The behavioral approach as intervention on preschoolers with the said disorder showed an affirmative short- and long-term effect (Anderson, Avery, DiPietro, Edwards, & Christian, 1987; Fenske, Zalenski, Krantz, & McClannahan, 1985; McEachin, Smith, & OI, 1993).
It was said that results showed a partial to nearly complete recovery from symptoms of autism where the most hopeful and positive result suggests a nearly 50% recovery through intensive early intervention (Handleman, Harris, Celiberti, Lilleheht, & Tomchek, 1991; Hoyson, 1984; Lord & Schopler, 1989; Lovaas, 1987; Sheinkopf & Siegel, 1998). The reported improvement was based on the outcomes from “standardized pre-post test scores” and at times, was based on behavioral outcomes (Handleman, Harris, Celiberti, Lilleheht, & Tomchek, 1991; Hoyson, 1984; Lord & Schopler, 1989; Lovaas, 1987; Sheinkopf & Siegel, 1998).
Also, in contrast to the previous approximations that implied only 50% of all children have a chance to learn to use “functional speech”, more recent approximations as based from participating children under early intervention showed at least 85% to 90% of these children can utilize the functional speech if intervention begins in the preschool stage (Koegel, 2000).
The intricacy in terms of mutual social interactions involved in autism disorders paved way to the need of early identification of this disorder to children because of the significant advantages that resulted if early intervention is performed. It is also this same complex nature on the social feature of autism that led to formulation of early intervention programs. But to date, there are few intervention programs that focus on the enhancement of social interactions to peer groups and siblings since most programs formulated were on “child-adult” interactions (Koegel, Koegel, & Frea, 2001).
There is also the inadequate outcome of these programs on the child’s “true” functioning in his or her natural environment such as social and behavioral improvements because most outcomes are based on the alterations of the child’s IQ scores and post-intervention assignments (Koegel, Koegel, & Smith, 1997). It was also noted that few assessment studies were conducted on the consequences or results of early intervention programs on autistic children less than three years of age since the knowledge of possibility for practitioners to diagnose autism prior to age three was only recent.
CHAPTER 1 The Historical Viewpoint behind Early Childhood Intervention Programs The concept that brain development can be manipulated during the early childhood period necessitates the need for early treatment or intervention of autism since this imposes a greater chance of success and the possibility of a long-term treatment being prevented and reduced (Ornitz, 1973). The trainings in communication, social learning, and self-help skills from the family, school, community, peers, and group can further help autistic children on their social and emotional development.
In an early intervention program, the factors being evaluated that become indicator if improvement occurred are age and IQ. There are studies showing that the incidence of a higher IQ and an earlier age at the start of intervention is a positive predictor of better chances of recovery and better outcomes (Gabriel, Hill, Pierce, Rogers, & Wehner, 2001; Handleman, Harris, Celiberti, Lilleheht, & Tomchek, 1991).
Recently, the recognized predictor of intervention outcome in the language and peer aspect is the stage of the child with autism on peer social avoidance after under intervention program for six months (Ingersoll, Schreibman, & Stahmer, 2001). Peer social avoidance is described as the frequency of the child’s avoidance near peers. Some studies showed a noteworthy connection of the child’s use of joint attention behaviors and later communicative language improvement (Mundy, Sigman, & Kasari, 1990).
These joint attention behaviors include eye gaze alternation and pointing. There is also a study demonstrating that child initiations anticipate very high favorable treatment outcomes (Koegel, Koegel, Shoshan, & McNerney, 1999). Child initiations are defined as the start of a new interaction or changing where the interaction is headed for. These three characteristics namely peer avoidance, joint attention, and initiations are described in nature as exceedingly analogous.
They are also called as intervention target behaviors. Before early intervention or treatment services are done, a proper and thorough evaluation of the child with autism should be conducted to identify the appropriate approach to conduct (Shackelford, 2002). First, this assessment should be performed by a trained staff to work on a suitable methods and procedures to be followed. Secondly, it should be based on “informed clinical opinion” from skilled medical professional for the said specialization.
And lastly, there should be a review of the relevant records that would be applicable in evaluating the child’s current health and medical history and child’s level of functioning on the critical development areas such as cognitive, physical (including vision and hearing, communication, social or emotional, and adaptive aspects (Shackelford, 2002). As defined, the term “early intervention” generally refers to program options for the child with autism at six years of age and below (“Early Intervention”, 2007).
There are many described and formulated different early intervention options specifically center-based programs for children with an array of developmental delays, conventional and expert preschool programs, center-based programs specializing in Autism Spectrum Disorder (ASD), home-based programs on a certain therapy approach, specific therapies from particular clinics, agencies that organize the early intervention personnel to visit the child’s home on a regular or semi-regular basis or outreach service, and programs that are investigated and organized with parents (“Early Intervention”, 2007).
There are many different types of services offered under the early intervention program. These are family support services, funded specialist programs, non-funded specialist programs, specific therapies, alternative therapies, and behavioral assistance services. Many family support services are available (“Early Intervention”, 2007). Example is the “Early Childhood Intervention Services” from the Department of Human Services that funds support programs like “Early Choices” and “Making a Difference” for a successful implementation of these programs.
The local councils can also render this support service as they are funded too to provide such (“Early Intervention”, 2007). The support and information service under family support services can help families through immediate guidance, sensible and emotional support, and provision of necessary information regarding autism through library, information packages and tip sheets, and published magazines (“Early Intervention”, 2007). The funded specialist programs are funded under the Department of Human Services purposely for children with Autism Spectrum Disorder (ASD) (“Early Intervention”, 2007).
These are center-based programs and outreach programs (“Early Intervention”, 2007). But still, funding is greatly limited and these funded programs are only available to offer services just a not so many hours per week. Outreach programs are where trained personnel visit the patient in his or her home, or are community based services such as child care or preschool for autistic children. The non-funded specialist programs are programs that do not receive funding from the federal government (“Early Intervention”, 2007). Example of this is the Applied Behavior Analysis (ABA).
The ABA is a home-based therapy that is structured in pattern to the work of Dr. Ivar Lovaas (“Early Intervention”, 2007). The format of this program is one-to-one instruction, and support and strengthening. But an ABA trained teacher or psychologist is the only one certified to develop and supervise the program. On the other hand, only the parent and/or trained ABA therapists can carry out the teaching conferences. It is known that ABA program outcomes are positive but still, as usual, the outcomes vary from child to child.
The only possible disadvantages being seen are on the financial and time viewpoints, that is, it is expensive and not all families can afford it (“Early Intervention”, 2007). Another type of service for early intervention is the conduction of specific therapies. These trained therapists are those already skilled in executing therapies in relation to autism (“Early Intervention”, 2007). These are the psychologists, speech therapists, occupational therapists, early intervention teachers, physiotherapists, music therapists, and dance and movement therapists.
Most of these therapists are in private practice and have explicit professional fees. Some families are able to secure funding from support programs while others have to pay it on their own. In year 2006, the federal government tried to include mental health conditions in Medicare insurances to help families to lessen expenditures if therapy is the proper approach to the autism condition of the child (“Early Intervention”, 2007). The identified alternative therapies are those treatments or approaches that showed constant positive outcomes (“Early Intervention”, 2007).
These are usually the educationally and/or behaviorally based programs (“Early Intervention”, 2007). These programs are intensive, planned, ordered, and long-standing. There is no instant approach. The behavioral assistance programs are more often than not where parents ask for help (“Early Intervention”, 2007). In view thereof, Gateways Support Services developed an interactive website with a large data bank as guidance for these parents (“Early Intervention”, 2007). Researchers and educators have debated the question of how communication goals and objectives for children with autism and related disabilities should be derived.
The perspective espoused by traditional behavioral programs has been to establish goals and objectives a priori (Lovaas, 1987). Behavioral discrete-trial programs begin with general compliance training to get a child to sit in a chair, look at the clinician, and imitate nonverbal behavior in response to verbal commands. Speech is taught as a verbal behavior, and objectives are targeted beginning with verbal imitation, following one-step commands, receptive discrimination of body parts, objects, person names and pictures, and expressive labeling in response to questions.
Later, language objectives include prepositions, pronouns, same or different and yes or no. More contemporary behavioral approaches have developed goals for outcomes from a functional assessment. Goals and objectives are individualized, based on a child’s repertoire of communicative behaviors, teaching functional equivalents of challenging behavior, and addressing the child’s individual needs. The functional emphasis focuses on goals that affect a child’s access to choices of activities in which to participate, opportunities for social interaction, and community settings (Brown, 2006).
Contemporary behavioral programs emphasize teaching communication skills so that greater access is provided to a variety of people, places and events, thereby enhancing the quality of life of children with autistic spectrum disorders. The perspective espoused by developmentally oriented approaches has been to focus on the communicative meaning of behaviors and to target goals and objectives that enhance a child’s communicative competence by moving the child along a developmental progression (Ornitz, 1973).
Contemporary developmentalists begin with social-communicative goals, including gaze to regulate interaction, sharing positive affect, communicative functions, and gestural communication. Language goals are mapped onto social communication skills and are guided by a developmental framework (Koegel, Koegel, & Frea, 2001). Developmental perspective usually guides the goal-setting in an augmentative and alternative communication (AAC) intervention.
Beukelman and Mirenda (1998) state that the goals of an AAC intervention are to assist individuals with severe communication disorders to become communicatively competent in the present, with the view toward meeting their future communication needs (Lovaas, 1987). One major purpose of communication assessment is to document change as an outcome measure of treatment. However, most formal or standardized language assessment measures focus primarily on language form and rely on elicited responses.
Because language impairments associated with autism are most apparent in social-communicative or pragmatic aspects of language, formal assessment instruments can provide information about only a limited number of aspects of communication for children with autism (Shackelford, 2002). Formal language measures are especially imprecise in measuring nonverbal aspects of communication and therefore are not sufficient, particularly for low-functioning children with autism. In many situations, the tests used for pre- and post-assessment are different, due to the child’s increasing age, making interpretation of results difficult.
Another major purpose of assessment is to provide information for educational planning that can be directly translated into goals, strategies, and outcome measures for communication enhancement. Several communication abilities have been identified as important to assess for children with autism like use of eye gaze and facial expression for social referencing and to regulate interaction, range of communicative functions expressed, rate of communicating, use of gestures and vocal/verbalizations, use of repair strategies, understanding of conventional meanings, and ability to engage in conversation (Shackelford, 2002).
It is pointed out that communicative abilities of children with autism should be documented in natural communicative exchanges, with a child’s symbolic abilities serving as a developmental frame of reference (Mundy, Sigman, & Kasari, 1990). To supplement formal measures, the systematic use of informal procedures to assess language and communication is needed. In order to gather an accurate picture of the communication and symbolic abilities of children with autism, a combination of assessment strategies has been recommended that includes interviewing significant others (i. e.
, parents, teachers) and observing in everyday situations to find out how a child communicates in the home, classroom, and other daily settings (Mundy, Sigman, & Kasari, 1990). Although there is consensus on the importance of enhancing communication abilities for children with autism, intervention approaches vary greatly, and some even appear to be diametrically opposed (Koegel, 2000). The methodological rigor in communication intervention studies in terms of internal and external validity and measures of generalization has been stronger than in many other areas of autism intervention studies.
Nevertheless, there have been relatively few prospective studies with controls for maturation, expectancy, or experimenter artifacts. The strongest studies in terms of internal validity have been multiple baseline, ABAB, or similar designs that have included controls for blindness of evaluations (Koegel, 2000). There have been almost no studies with random assignment, although about 70 percent of the studies included well-defined cohorts of adequate sample size or replication across three or more subjects in single subject designs.
A substantial proportion of communication interventions have also included some assessment of generalization, though most often not in a natural setting (Koegel, 2000). In order to examine the critical elements of treatment programs that affect the speech, language, and communication skills of children with autism. It is then useful to characterize the active ingredients of treatment approaches along a continuum—from traditional, discrete trial approaches to more contemporary behavioral approaches that used naturalistic language teaching techniques to developmentally oriented approaches (Koegel, 2000).
The earliest research efforts at teaching speech and language to children with autism used massed discrete trial methods to teach verbal behavior by building labeling vocabulary and simple sentences. Lovaas (1987) provided the most detailed account of the procedures for language training using discrete trial approaches. Outcomes of discrete trial approaches have included improvements in IQ scores, which are correlated with language skills, and improvements in communication domains of broader measures, such as the Vineland Adaptive Behavior Scales (McEachin, Smith, & OI, 1993).
A limitation of a discrete trial approach in language acquisition is the lack of spontaneity and generalization. Lovaas (1987) stated that “the training regime…its use of ‘unnatural’ reinforcers, and the like may have been responsible for producing the very situation-specific, restricted verbal output which we observed in many of our children”. In a review of research on discrete trial approaches, Koegel (2000) noted that “not only did language fail to be exhibited or generalize to other environments, but most behaviors taught in this highly controlled environment also failed to generalize”.
There is now a large body of empirical support for more contemporary behavioral approaches using naturalistic teaching methods that demonstrate efficacy for teaching not only speech and language, but also communication. According to Koegel 2000, there are many approaches that could be considered that include natural language paradigms (Koegel et al. , 1987), incidental teaching (Hart, 1985; McGee et al. , 1985; McGee et al. , 1999), time delay and milieu intervention (Charlop et al.
, 1985; Charlop and Trasowech, 1991; Hwang and Hughes, 2000; Kaiser, 1993; Kaiser et al. , 1992), and pivotal response training (Koegel, 1995; Koegel et al. , 1998). These approaches use systematic teaching trials that have several common active ingredients: they are initiated by the child and focus on the child’s interest; they are interspersed and embedded in the natural environment; and they use natural reinforcers that follow what the child is trying to communicate.
Only a few studies, all using single-subject designs, have compared traditional discrete trial with naturalistic behavioral approaches. These studies have reported that naturalistic approaches are more effective at leading to generalization of language gains to natural contexts (Koegel 2000). There are numerous intervention approaches based on a developmental framework. While there are many different developmental programs, a common feature of developmental approaches is that they are child-directed.
The environment is arranged to provide opportunities for communication, the child initiates the interaction or teaching episode, and the teacher or communicative partner follows the child’s lead by being responsive to the child’s communicative intentions, and imitating or expanding the child’s behavior. Although the empirical support for developmental approaches is more limited than for behavioral approaches, there are several treatment studies that provide empirical support for language outcomes using specific strategies built on a developmental approach providing the largest case review.
Developmental approaches share many common active ingredients with contemporary naturalistic behavioral approaches and are compatible along most dimensions. Many researches had been done on the effectiveness of “early intervention” because a proper selection of goal when dealing the autistic spectrum disorder should be done since the disorder is characterized of many complexities that treating it also involves critical selection of approach. In general, it was shown that researches on these intervention programs had focused on the effectiveness of the programs and not the appropriateness of different goals.
For example is knowing a certain intervention program to be effective but the parent and child had to travel across town once a week for the said program or the child is taken out from class in order to be treated by his therapist. Educational objectives must be based on specific behaviors targeted for planned interventions. However, one of the questions that arises repeatedly, both on a theoretical and on a clinical basis, is how specific a link has to be between a long-term goal and a behavior targeted for intervention.
Some targeted behaviors, such as toilet training or acquisition of functional spoken language, provide immediately discernible practical benefits for a child and his or her family. However, in many other cases, both in regular education and specialized early intervention, the links between the objectives used to structure what a child is taught and the child’s eventual independent, socially responsible functioning are much less obvious. This is particularly the case for preschool children, for whom play and manipulation of toys (e. g. , matching, stacking of blocks) are primary methods of learning and relating to other children.
Often, behaviors targeted in education or therapy are not of immediate practical value but are addressed because of presumed links to overall educational goals. The structuring of activities in which a child can succeed and feel successful is an inherent part of special education. Sometimes the behavior is one component of a series of actions that comprise an important achievement. Breaking down a series of actions into components can facilitate learning. Thus, a preschool child may be taught to hold a piece of paper down with one hand while scribbling with another.
This action is a first step in a series of tasks designed to help the child draw and eventually write. Other behaviors, or often classes of behaviors, have been described as “pivotal behaviors” in the sense that their acquisition allows a child to learn many other skills more efficiently (Koegel, Koegel, Shoshan, & McNerney, 1999). Schreibman and the Koegels and their colleagues have proposed a specific treatment program for children with autism: pivotal response treatment. It includes teaching children to respond to natural reinforcers and multiple cues, as well as other “pivotal” responses.
These are key skills that allow better access to social information. The idea of “pivotal skills” to be targeted as goals may also hold for a broad range of behaviors such as imitation (Stone, 1997; Rogers and Pennington, 1991), maintaining proximity to peers (Hanson and Odom, 1999), and learning to delay gratification (understanding “first do this, then you get to do that”). Longitudinal research has found that early joint attention, symbolic play, and receptive language are predictors of long-term outcome (Siller and Sigman, 2002).
Although the research to date has been primarily correlational, one inference has been that if interventions succeed in modifying these key behaviors, more general improvements will occur as well (Kasari, 2000). Another explanation is that these behaviors are early indicators of the child’s potential developmental trajectory. Sometimes goals for treatment and education involve attempting to limit and treat the effects of one aspect of autism, with the assumption that such a treatment will allow a child to function more competently in a range of activities.
For example, a number of different treatment programs emphasize treating the sensory abnormalities of autism, with the implication that this will facilitate a child’s acquisition of communication or social skills (e. g. , auditory integration; sensory integration). For many interventions, supporting these links through research has been difficult. There is little evidence to support identifiable links between general treatment of a class of behaviors (e. g. , sensory dysfunction) and improvements in another class of behaviors (e. g.
, social skills), especially when the treatment is carried out in a different context from that in which the targeted behaviors are expected to appear. However, there are somewhat different examples in other areas of education and medicine in which interventions have broad effects on behavior. One example is the effect of vigorous exercise on general behavior in autism (Koegel, Koegel, Shoshan, & McNerney, 1999). In addition, both desensitization and targeted exercise in sports medicine and physical therapy often involve working from interventions carried out in one context to generalization to more natural circumstances.
Yet, in both of these cases, the shift from therapeutic to real-life contexts is planned explicitly to occur within a relatively brief period of time. At this time, there is no scientific evidence of this kind of link between specifically-targeted therapies and general improvements in autism outside the targeted areas. Until information about such links becomes available, this lack of findings is relevant to goals, because it suggests that educational objectives should be tied to specific, real-life contexts and behaviors with immediate meaning to the child.
Because the range of outcomes for children with autistic spectrum disorders is so broad, the possibility of relatively normal functioning in later childhood and adulthood offers hope to many parents of young children. Although recent literature has conveyed more modest claims, the possibility of permanent “recovery” from autism, in the sense of eventual attainment of language, social and cognitive skills at, or close to, age level, has been raised in association with a number of educational and treatment programs (Ingersoll, Schreibman, & Stahmer, 2001).
Natural history studies have revealed that there are a small number of children who have symptoms of autism in early preschool years who do not have these symptoms in any obvious form in later years. Whether these improvements reflect developmental trajectories of very mildly affected children or changes in these trajectories (or more rapid movement along a trajectory) in response to treatment (Lovaas, 1987) is not known. However, as with other developmental disabilities, the core deficits in autism have generally been found to persist in some degree in most persons with autistic spectrum diagnoses.
There is no research base explaining how “recovery” might come about or which behaviors might mediate general change in diagnosis or cognitive level (Ingersoll, Schreibman, & Stahmer, 2001). Although there is evidence that interventions lead to improvements and that some children shift specific diagnoses within the spectrum and change in severity of cognitive delay in the preschool years, there is not a simple, direct relationship between any particular current intervention and “recovery” from autism.
Because there is always room for hope, recovery will often be a goal for many children, but in terms of planning services and programs, educational objectives must describe specific behaviors to be acquired or changed. Research on outcomes (or whether goals of independence and responsibility have been attained) can be characterized by whether the goal of an intervention is broadly defined (e. g. , “best outcome”) or more narrowly defined (e. g. , increasing vocabulary, increasing peer-directed social behavior); whether the study design involves reporting results in terms of individual or group changes; and whether goals are short term (i.
e. , to be achieved in a few weeks or months) or long term (i. e. , often several years). A large body of single-subject research has demonstrated that many children make substantial progress in response to specific intervention techniques in relatively short time periods (e. g. , several months). These gains occur in many specific areas, including social skills, language acquisition, nonverbal communication, and reductions of challenging behaviors. Often the most rapid gains involve increasing the frequency of a behavior already in the child’s repertoire, but not used as broadly as possible (e. g.
, increasing use of words) (Mundy, Sigman, & Kasari, 1990). In single-subject reports, changes in some form are almost always documented within weeks, if not days, after the intervention has begun. Studies over longer periods of time have documented that joint attention, early language skills, and imitation are core deficits that are the hallmarks of the disorder, and are predictive of longer-term outcome in language, adaptive behaviors, and academic skills. However, a causal relationship between improvements in these behaviors as a result of treatment and outcomes in other areas has not yet been demonstrated.
Many treatment studies report post intervention placement as an outcome measure (Mundy, Sigman, & Kasari, 1990). Successful participation in regular education classrooms is an important goal for some children with autism. However, its usefulness as an outcome measure is limited because placement may be related to many variables other than the characteristics of a child (such as prevailing trends in inclusion, availability of other services, and parents’ preferences).
The most commonly reported outcome measure in group treatment studies of children with autism has been IQ scores (Lord & Schopler, 1989). Studies have reported substantial changes in IQ scores in a surprisingly large number of children in intervention studies and in longitudinal studies in which children received nonspecific interventions. However, even in the treatment studies that have shown the largest gains, children’s outcomes have been variable, with some children making great progress and others showing very small gains.
Overall, while much evidence exists that education and treatment can help children attain short-term goals in targeted areas, gaps remain in addressing larger questions of the relationship between particular techniques and both general and specific changes (Lord & Schopler, 1989). The child with autism is also protected in the federal state law. These are the Public Law 108-77 also called Individuals with Disabilities Education Improvement Act of 2004 and Public Law 105-17 also called Individuals with Disabilities Act or IDEA of 1997.
This mandates the major care provider to refer the child with autism and the family to an early intervention service. It was stated that every state has an early intervention program and must make it available to children from birth to three years of age, thus, autistic children are covered under this law. Examples of these program are behavioral methods, early developmental education, communication skills, occupational and physical therapy, and structured social play.