Autism Spectrum Disorders (ASD) encompass a group of disorders characterized by deficits in social skills and interactions, impairments in speech and communication, and unusual and repetitive behaviors.  The degree of autism varies in each individual, from high cognitive functioning to severe mental retardation.  Autism is considered to be a spectrum disorder because symptoms vary so widely from one individual to the next. 

            The National Institute of Mental Health estimates that Autism Spectrum Disorders affect one of every five hundred children or 20 in 10,000 (2004).  The National Institute for Health (NIH) suggests that when Asperger syndrome is included, that numbers jump to 50 in 10,000 (Jacobson, n.d.).  According to the National Alliance for Autism Research, autism spectrum disorders are 10 times more prevalent than they were 10 years ago and are the second most common developmental disability, next to mental retardation (2005).  John W. Jacobson, Ph.D. with the Association for Science in Autism Treatment (ASAT) suggests that there are two causes for the popular belief that autism is on the rise.  The first is the introduction of Asperger syndrome, which has milder symptoms than the other disorders in the spectrum and so, may be easier to misdiagnose.  The second cause for the increase in autism diagnoses is that service providers may be pushing for the diagnosis in order to secure better treatment options for their clients (Jacobson, n.d.). 

            Effective treatment of autism is a continually debated issue.   Many areas of controversy exist including teaching methods, intensity of instruction, and the value of early intervention programs.  Most experts agree that children with ASD can be expected to make significant progress if they are diagnosed early and have early exposure to structured, consistent programs based on effective intervention and educational methods (Simpson, 2001).  Simpson writes in the Fall 2005 issue of Focus on Autism and other Developmental Disabilities:

Highly unique and idiosyncratic characteristics associated with ASD, manifestation of irregular and occasionally even advanced skills that accompany diagnoses of autism, and a remarkably increased prevalence of ASD are only a few of the factors that have fueled significant debate about which treatment and intervention choices are most apt to lead to favorable outcomes (p.141).

            Empirical data on the success of treatment methods has not shown definitive results.  There are several methods of treatment that have been published and studied including individualized education programs, Treatment and Education of Autistic and Communication Handicapped Children (TEACCH), Applied Behavior Analysis (ABA) including discrete trial training, facilitated communication, positive behavior interventions, and pharmacological treatments.  Although there have been many studies on the topic, there is no proven single best universally effective method for all children with ASD (Simpson, 2005).   

History of Autism

            The first identification of autism is credited to Dr. Leo Kramer who published a paper on the disorder in 1943.  The following year, Dr. Hans Asperger published another paper describing a similar disorder that is now known as Asperger Syndrome.  In the 1950’s and 1960’s, it was believed that detached or uncaring mothers were the cause of autism.  This theory was proven wrong and was replaced by the theory that genetics were to blame.  Harris and Delmolino hypothesized that multiple biological causes may produce autism (2002).  Currently there is still no definitive cause that can be medically proven to account for autism spectrum disorders.  There is also no known cure.   

Diagnosis

The National Alliance for Autism Research’s website (2005) identifies five disorders that fall into the ASD diagnosis:

¨        Autistic Disorder- This disorder is usually referred to as classic autism.  It affects a person’s communication skills, interferes with the forming of relationships, and can cause the individual to respond inappropriately to the environment.

¨        Asperger Syndrome- This disorder does not cause a delay in speech development but can impact other communication and social skills.  People with Asperger’s also tend to be obsessive with repetitive routines.

¨        Childhood Disintegrative Disorder (CDD)- This disorder is referred to as regressive autism in that children develop normally for two to four years then develop characteristics associated with autism disorder. 

¨        Rett Syndrome- This disorder is genetic and mainly affects girls who develop normally for 6 to 18 months and then begin to regress.  Deceleration of head growth and loss of purposeful hand movements characterize this disorder. 

¨        Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS)- People diagnosed with this disorder have some of the symptoms of autism disorder but do not meet all of the criteria for any of the other disorders in the autism spectrum.

            Children with an autism spectrum disorder usually show symptoms by the age of 18 months.  There are specific behaviors or symptoms that when deficit will identify a child that needs to be evaluated for autism.  The NAAR website suggests that these can include a child who does not babble, coo, point, or wave by age one and has no spoken words by 16 months (2005).  These are only a few of the many behaviors that may be deficit.  Children with autism may not respond to their name, make eye contact or follow verbal directions.  They may have odd movement patterns and unusual attachments to toys or other objects (Sprock, 2004).    

            Children with autism typically have the following traits although they differ widely in severity:

¨        Communication delays- Many children with autism do not develop speech.  Those that are verbal may use a flat tone lacking inflection or expression.  Often they exhibit unusual speech patterns such as echolalia, which is repeating what has been heard.  It may be difficult to interpret the body language of a child with autism as facial expressions, movements and gestures may not match what the child is saying (Sprock, 2004). 

¨        Repetitive behaviors- Although most children with autism appear physically normal they may have body movements that are easily identifiable as symptomatic of autism.  Hand flapping, walking on toes, or moving in circles are behaviors that may be exhibited.  Attention to detailed order may also be a characteristic behavior of an individual with autism.  For example, obsessive behavior such as lining up objects and becoming upset if objects are moved out of place is common.  Children with autism “need and demand absolute consistency in their environment” (Sprock, 2004, para. 19).   

¨        Social symptoms- Children with autism may not be able to interpret gestures or facial expressions during conversion.  They also may not respond appropriately to tone of voice.  They miss social cues and may appear unresponsive.  They have difficulty understanding the environment around them and so they may be unable to predict or understand the actions of others (Sprock, 2004).  Children with autism may not regulate their emotions and so may appear immature for their age.  They may lose control, becoming angry and frustrated when they are in a strange or overwhelming environment.  They may be physically aggressive towards others or themselves during these outbursts.  

Other problems that affect children with autism are sensory in that many individuals are highly sensitive to sounds, tastes, smells and textures.  They may also have some degree of mental retardation. Two to five percent of people with ASD have Fragile X syndrome, an inherited form of mental retardation.  One in four children with autism also have seizures and one to four percent of individuals with ASD have tuberous sclerosis which causes benign tumors in the brain (Sprock, 2004)

Treatments

            Early intervention treatment programs for children with autism typically have basic elements in common.  Gresham, Beebe-Frankenberger & MacMillan (1999) write,

One element that is common across programs is curriculum content that emphasizes five basic skill domains: ability to selectively attend to stimuli in the environment, imitative ability including both verbal and motor imitation, receptive and expressive language ability, appropriate play and social interaction skills (p. 569).

Other common elements of these programs are that they provide highly supportive environments for learning and structured teaching principles are used.  Most treatment methods also use a functional approach to deal with problem behaviors.  They focus on the causes and functions of behavior such as “task escape/avoidance, social attention, access to tangible reinforcers and automatic or sensory reinforcement” (Gresham, et al., 1999, p. 570).  Family involvement is also a common component of early intervention programs. 

Studies have been conducted on many different treatments and the most agreed upon point is that no one treatment is effective for all individuals with autism.  Two widely used treatment approaches that have emerged are Applied Behavior Analysis (ABA) and Treatment and Education of Autistic and related Communication Handicapped Children (TEACCH).  Both methods are based on the concepts that children with autism have unique learning needs and require specialized services.  The programs also share the goal of helping individuals with autism to become independent.  Both are highly structured approaches to treatment and use consequences to motivate students (Jennett, Harris & Mesibov, 2003).       

Applied Behavior Analysis

Applied Behavior Analysis (ABA) is characterized by the “discrete presentation of stimuli with responses followed by immediate feedback, and intense schedule of reinforcement, data collection, and systematic trails of instruction” (Schoen, 2003, p. 125).  ABA encompasses several different treatment methods.  These include Mand training, Natural Environment Training (NET), and the treatment most often associated with ABA, Discrete Trial Training (DTT).  Dr. O. Ivar Lovass of the University of California at Los Angeles, who first developed a method for treating young children with autism, is considered to be the “father” of discrete trail training (Yell & Drasgow, 2000).   His treatment involved intensive therapy sessions, up to 40 hours per week, for 2 to 3 years. The program involved trained staff working in the home where they worked with children and also taught families ABA skills (Harris & Delmolino, 2002).  Lovaas’ programs address declining aggressive behaviors, increasing expressive language, teaching appropriate play, interaction with peers, appropriate expressions and emotions and learning pre-academic skills (Schoen, 2003).  In 1987, Lovass reported that his treatment method resulted in significant progress with preschool children.  Further studies have shown similar outcomes supporting the hypothesis that intensive treatment can provide significant benefits for some children with autism (Harris & Delmolino, 2002).  Studies also suggest that intensive intervention for young children with autism, such as the Lovass method, increase the child’s chances of being included in a regular education classroom when they reach school age (Harris & Demolino, 2002).

Discrete Trial Training (DTT) is a program that is reported to yield long-term benefits for children with autism (Smith, 2002).  It is especially useful in teaching new skills and behaviors involving communication and fine motor skills.  DTT uses an operant conditioning method that is “a careful, deliberate, and specific organization of antecedent and consequent stimuli” (Harris & Delmolino, 2002, p. 14).  DTT is a behaviorally based intervention that tackles many of the symptoms of autism. Specific focus is given to compensate for specific areas of difficulties (Wallin, 2004):

¨        Attention span- In DTT, tasks are broken down into small, simple tasks.  As the child’s attention span increases, the length of the tasks increase accordingly.

¨        Motivation- Tangible reinforcers are used as rewards when desired behaviors are performed and tasks are completed.  Social praise is also used and eventually replaces tangible reinforcers.

¨        Stimulus control- DTT teaches the child to distinguish between important and non-important stimuli.  It does this by rewarding behaviors to important and consistent stimuli.  

¨        Generalization- Using DTT, the application of skills and behaviors across different environments is taught by changing the program content and context over time so the child with autism learns to generalize previously learning.

¨        Cause and effect- Children with autism have difficulty with observational learning.  DTT teaches skills and behaviors explicitly.

¨        Communication- Children with autism may have deficits in expressive and receptive language.  DTT uses instructions that are simple and concrete.  As a child progresses, instructions increase in complexity.

The discrete trial method uses cycles of behaviorally based instruction routines (Wallin, 2004).  A discrete is a small unit of instruction, usually lasting 5-20 seconds, which is taught in a setting with minimal to no distractions (Smith, 2001).  It is taught by a teacher who works one on one with a child.  DTT includes a discriminative stimulus for instruction, a prompting stimulus for desired behavior, a response, the reinforcing stimulus, and the inter-trial interval or wait time between consecutive trials (Wallin, 2004).  When a new skill is taught, verbal and visual cues or prompts are given to instruct the child to perform the desired task or behavior.  As the child begins to demonstrate the correct response, prompts are faded until the child is able to respond independently. 

Applications for DTT include teaching discrimination skills such as imitation.  Many children with autism have few or no imitation skills and “DTT is the only teaching method that has been clearly shown to enable children to imitate actions such as clapping, waving, play activities…and speech sounds…” (Smith, 2001, para. 12).  DTT also helps children with receptive language deficits in that they are asked for a response to a verbal cue.  Another application of DTT is to improve expressive language where a verbal response is requested upon the presentation of a visual cue.  DTT is also an effective method for teaching picture communication systems.  DTT can be used in behavior management as well, to teach alternative, appropriate behaviors to replace disruptive ones.  

An important caveat to using DTT is that it should be combined with other interventions to allow students to use their skills across different settings.  DTT is designed to use a tightly controlled learning environment where children may not transfer the skills they have learned to other environments (Smith, 2001).  DTT is also very labor intensive requiring the teacher’s one on one attention for the child.  It also may require significant hours of DTT each week although how many hours are appropriate is a controversial issue (Smith, 2001).  As Smith concludes “investigators have much work to do to determine how best to combine DTT with other approaches, how much DTT children should receive, and how to increase the supply of teachers qualified to provide it” (2001, para. 36). 

When a child first begins DTT sessions, when new skill acquisition is most difficult, they often resist the teaching process.  Newman, Needelman, Reinecke and Robeck (2002) completed a study to determine if introducing student choice-making into a teaching program increased skill acquisition.  The authors were also looking for decreased competing behaviors that reduce student learning.  Each student in the experiment was allowed to choose the order of their learning programs that were to be taught during the school day.  During alternate days, the teacher or the students chose the order. Their choices were from the same inventory as the teacher’s.  The programs available were the same and all programs were completed each day.  Only the order differed. The students were also given the choice of the enforcer or reward for each learning task. 

It was found that there was no difference in the speed of skill acquisition between students that were given choices and those that were not. It was also found that “competing behavior was lower during student-selected conditions, versus teacher-selected conditions (Newman et al., 2002, p. 40).  The conclusion of the study was that increasing student choice has the benefit of decreasing student resistance to learning and at no cost.  It improved student engagement and made it easier for teachers to work with their students during DTT sessions. 

TEACCH     

            A child research project at the University of North Carolina, Chapel Hill is credited for creating TEACCH, the Treatment and Education of Autistic and Communication Handicapped Children.  TEACCH is based on the work of Eric Schopler who created a program that was adopted statewide to meet the needs of individuals with autism (Tissot & Evans, 2003). The treatment method is based on the fundamental principles that children with autism need individualized education programs, environmental adaptations and alternative communication (Panerai, Ferrante & Zingale, 2002).  The TEACCH method emphasizes parental involvement and collaboration with professionals and acknowledges that parents are the experts regarding their child’s unique characteristics (Gresham, et al., 1999).  The program is designed to teach people with autism, and their family, skills that can be used to live more effectively by reducing or removing autistic behaviors. 

TEACCH’s premise is to adapt the environment to accommodate the child. The method focuses on the presumed visual processing strengths of children with autism.  It provides a structured learning environment that focuses on physical organization, schedules, work systems, and task organization (Gresham et al., 1999).  It emphasizes the development of social, vocational and living skills through the use of visual cues that can be used by the individual with autism to adapt their environment throughout their lives.  Studies have shown the effectiveness of TEACCH in “reducing self-injurious behaviors in high-functioning students with Asperger syndrome and individuals who are entering the job market…” (Panerai, et al., 2002, p.319). 

The TEACCH treatment method combines unique strategies, used for children with autism, that are not found in all regular classroom settings.  Physical organization is important.  The arrangement of furniture in the classroom can support a student’s independent functioning by facilitating recognition and compliance with rules and limits (Marcus, 2005).  Students with autism may have problems knowing where to be or how to get there and so need clear division of areas, with boundaries within the classroom.  The classroom setup should include borders which may consist of partitions, bookshelves, tables, rugs or even tape on the floor to signify to the student that they are moving from one area to another (Marcus, 2005). 

Areas in the classroom should be set up for specific activities.  Students with autism need a clear and predictable environment which Panerai, et al. describe as a place-activity correspondence (2002).  Workstations for individual speech therapy and an area designated for group reading are examples of classroom areas where specific tasks are completed.  The child with autism can predict what will be happening in specific areas, which helps them stay calm and give attention to the expected task. 

Communication systems are also an important principle of the TEACCH method. Students with autism may become anxious about not knowing what comes next.  It is difficult for many students with autism to understand the abstract concept of time.  Time must be made visible so students can see the schedule of their day and know that after an activity is completed, they can expect the next task on their schedule.  Students need to understand what they will be doing and when they will be doing it.  Pictorial schedules are created based on the student’s level of development.  These may include drawings, photographs, written words or other visual representations of activities.  These visual representations usually include both the classroom schedule and the child’s individualized daily activities.  The classroom schedule shows the sequence of activities throughout the school day and is general in nature.  The child’s personal schedule is based on the child’s individualized activities that will be performed during the general activities listed on the classroom schedule.  These individually oriented schedules contain tasks that are developmentally appropriate for the student, balance difficult and rewarding tasks, and are based on the student’s endurance levels (Marcus, 2005). Schedules can address receptive communication delays but there are also expressive communication tools that are used to facilitate interactions for children with autism. 

It is estimated that 50% to 80% of children with autism are functionally mute (Tissot & Evans, 2003). It is noted that “most [children with autism] communicate a great deal, although how they attempt to communicate may not always be socially desirable, and what they are attempting to communicate may prove difficult to establish” (Tissot & Evans, 2003, p. 427).  Without the ability to communicate effectively, children with autism may develop other methods of expressing themselves such as tantrums, aggression or self-injurious behavior.  Communication systems for these children must be individualized. 

The Picture Exchange Communication System or PECS uses small cards that are used by a child to express their wants and needs.  These cards typically contain pictures and words of items and activities that the child desires.  The child is taught to hand the card to an adult as a means of requesting that item.  When the adult then gives the child the requested item, the child will begin to understand that this is a way to access things they want (Tissot & Evans, 2003).

Routines are another important component of TEACCH.  Routines help children with autism to become more independent.  As with predictability of physical environments, routines help students with autism to remain calm during transitions because they learn to expect certain outcomes.  Routines that are taught may include physical movement during the school day, an expected reward after task completion or the order in which the steps of a task are performed.  When the child has learned the routine they will be able to function with less intervention. 

Children with autism may have difficulty with the organization and directions needed for task completion.  The use of prompts and reinforcers should be systematic and organized to make learning situations more predictable.  Students with autism may need help to overcome deficits is attentiveness, motivation and their ability to accept change. Based on the child’s unique needs, the TEACCH method emphasizes that activities should be presented using “specifically designed material, which is individualized and perceptually clear” (Panerai, et al., 2002, p. 322).  Materials need to be clearly marked and arranged and may include color coding, number symbols or pictures to help students understand how to categorize, acquire, and store materials independently (Marcus, 2005).  Organizing student tasks consistently helps students to learn to complete work more autonomously.  Uniformly performing task steps from right to left or bottom to top is a strategy that can be taught to help students who do not where materials are, how to start a task, or how to know when they are finished.  Using visual or written instructions to identify the correct sequence of steps to complete a task can help students however teachers must be careful to not provide too many visual cues, as they may become distracting.  Teachers can also reduce confusion by only providing materials needed for a specific task and clearing the work area of other materials that may divert the student’s attention from their work.  

ABA versus TEACCH

Both ABA and TEACCH stress that the teaching environment is important.  The programs both structure the environment in ways that facilitate spontaneous use of communication and the teaching of communication skills (Jennett, et al. 2003).  The approaches use students’ strengths, such as visual processing abilities, to develop skills in areas of weakness.  They also agree with the concept that students with autism can more easily learn complex skills when these are broken down into small tasks or steps.      

            There are some fundamental differences between ABA and TEACCH.  Jennett, et al. (2003) highlights that “one aim of ABA is to help the individual with autism appear indistinguishable from his or her peers…This contrasts with a primary value of the TEACCH approach of respecting the culture of autism” (p.584).  It seems that ABA tries to change the individual to fit the environment and TEACCH works to change the environment to fit the individual. 

ABA focuses on teaching students new skills.  The focus of TEACCH is for students to understand the process of learning and how to apply their skills.  ABA uses external reinforcers to engage students in tasks.  TEACCH uses structured activities to promote the clear understanding of tasks and therefore the student becomes more engaged in their learning (Jennett, et al., 2003).  ABA uses observable variables or behaviors to teach skills while TEACCH focuses on unobservable variables, trying to understand the child’s perception of the environment and how the child is acquiring information (Jennett, et al. 2003).

Both approaches have led to successful outcomes for students although there is no agreement on which one is the best for children with autism.  Children’s needs vary across the range of Autistic Spectrum Disorders.  No one treatment alone will be able to address all of the diverse needs of this population.  A combination of treatments is likely the most effective way to treat autism.  The key is that whatever treatment is used, it must be individualized for each student based on their unique learning needs.