Autism Series Part III: How to choose an ASD treatment option for your child
Spin the Wheel! Big money, big money…Trying to select an appropriate ASD treatment option for your child might feel a lot like being a contestant on the Wheel of Fortune. You’re up and it’s time to spin. There are a few great places to land that might end up changing your life, but you could also end up on the wrong tile and be helpless, frustrated and broke. You’re not sure what to do so you look for help from the other contestants trying to solve the same puzzle. You look to your left and see a lady who is really struggling and ready to pull her hair out. This gives you some guilty comfort, but then you look to the right and this guy gets it, he keeps landing on the proverbial $50000 tile. He’s having success, but he can’t explain it or tell you how he does it.
Now back to real life. Some ASD families appear to struggle while some seem overly optimistic, happy and content. The successful treatment of ASD at an early age is directly related to the child’s ability to function as an adult. So, let’s face it,if ever there was a time for paralysis by analysis this would be the time. I’ve had a hard time choosing which dentist gets to torture my child by cleaning his teeth, choosing an ASD treatment option must be nerve wracking. It’s only more complicated due to the large financial investment that is often required. It’s understandable that parents struggle deciding which ASD treatment intervention to start with. As the parent who is asked to make this difficult choice, it may feel like you’re spinning a wheel of chance. Part III of this series includes a thorough review of ABA, DTT, PRT, and ESDM which are professional,clinically researched, treatment options. This post also provides a very objective analysis of each option, and provided simple information related to costs, time commitment, and success rates if available. Keep reading, and you’ll see that I’ve included Qijong Massage – a newly published research option that claims to have significant results through daily parent given massage treatment.
Last thing before we get started, I am not providing you with professional advice regarding your specific situation and would encourage you to continue researching options most appropriate for your child based on their strengths and needs.
Let’s get started.
The Bread and Butter: Applied Behavioral Analysis
The majority of the treatment options for ASD are developed under the principles of Applied Behavioral Analysis (ABA). ABA was developed by B.F. Skinner in the 1930’s. You’re probably familiar with Skinner’s work through his popular coined buzz word “operant conditioning”. Operant Conditioning can be simply defined as the “changing of behavior by the use of reinforcement which is given after the desired response.” In simple terms, when you see a “good” behavior, you want to reward or reinforce that behavior to improve the likelihood of seeing that behavior again, NO MATTER HOW SMALL the behavior is. ABA therapy consists of reinforcing positive behaviors and decreasing negative behaviors through the ABC’s of operant conditioning. (A) Antecedent, (B) Behavior, and (C) Consequence (or reward). The ABC’s are the foundation of behavioral focused therapy and are key components of what Smarter Parenting uses with the Teaching-Family Model.
I’ll give you two examples of the same situations
Your son stays up really late playing video games. In the morning he struggles to wake up on time, misses the bus and walks to school, making him an hour late.
Antecedent: staying up late
Behavior: Doesn’t wake up on time
Consequence: Has to walk to school.
Because your son has struggled going to bed on time, you create a rule that video games are unplugged at 9 PM on school nights. Your son goes to bed at 9:00 pm and gets plenty of sleep. The next morning your son wakes up on time and catches the bus. The morning went really well, when he returns from school you give him an extra 30 minutes of video game time before dinner.
Your son now understands that if he wants to earn more video game time he can, but he has to go to bed on time, wake up early and catch the bus.
Antecedent: Going to bed early
Behavior: Waking up early
Consequence (reward): Extra video game time
These were simple examples to describe the basic tenets of the ABC’s in operant conditioning. ABA is an intensive intervention that requires up to 25-30 hours per week of in-home therapy, and an ABA therapist might use 40-50 structured role plays per session. Weekly goals are set to target autism symptoms and to increase the likelihood of positive behaviors and reducing negative behaviors. ABA has been used by thousands of practitioners to develop behaviors such as greeting skills, hygiene skills, academic skills, and social skills. There is a significant amount of research that suggests that ABA is an evidenced based treatment modality for behavior change for children with ASD. My personal belief is that this model has consistent success due to the very concrete thinking amongst the ASD population. This is a very straight forward, clear and direct treatment option. Due to the intensive nature of ABA therapy, it can be very expensive for families and ABA therapists may charge up to $40-$120 an hour.
How much does ABA therapy cost?
Here is a great link to a resource with information on insurance companies, paying through your school district, and describing private payment plans.
DISCRETE TRIAL TRAINING
Discrete Trial Training (DTT) is a simplified form of ABA. Instead of teaching an entire skill at a time, the skill is broken down and “built-up” using discrete trials that teach each step one at a time The curriculum stresses the importance of using several repeated teaching trials of one specific step until that step is mastered. Then steps are built on top of one another and children are then encouraged and expected to use several steps in order. DTT also uses reinforcers that do not have to be intrinsically related to the skill being taught. Most DTT programs consist of 25 to 40 hours per week and typical DTT sessions occur in 3-5 minute increments dozens of times where the client is involved in a very structured practice. Each skill is broken down into small steps, and taught using prompts, which are gradually eliminated as the steps are mastered. The child is given repeated opportunities to learn and practice each step in a variety of settings. Each time the child achieves the desired result, he receives positive reinforcement.
Here’s an example.
Tying Your Shoes
First step: Give a prompt. Your daughter practices finding matching shoes from the shoe rack. Give a small reward.
Second step. Give a prompt. Your daughter practices putting the shoes on the right feet. Give a small reward.
Third step. Give a prompt. Your daughter practices tying one shoe. Give a small reward.
Fourth Step. Give a prompt. Your daughter practices tying the other shoe. Give a small reward.
When your daughter completes each step she earns a small reward and a small break. Practice sessions last 3-5 minutes. With enough structured practices, the prompts go away and the steps merge together. The rewards do not have to be related to the behavior at this point and she can earn a small sticker, hug, high five etc. A few minutes later, the practice begins and she ties her shoes again, earns a small sticker. She becomes faster and faster at tying her shoes and her breaks in between practice get longer. She may trade in the stickers at the end of the day for a larger reward or maybe she is simply motivated by having several dozen princess stickers. Your daughter then practices tying her shoes in the front yard, back yard, school bus, grocery store etc. At the end of a successful session, she will have practiced tying her shoes dozens of times in several different places. The following day the DTT therapist may ask her to practice tying her shoes to determine if your daughter has retained the skill of tying her own shoes. If so, the therapist moves on to practicing a new behavior. If not, the therapist may spend more time reinforcing and building the skill of tying shoes.
DTT also uses the ABC’s of Behavior and places a strong emphasis on the child’s surrounding environment, for example; parks, play grounds, school settings
Structured Play time with friends in a one-on-one environment is a key component of DTT. “Play Skills” can be broken down into small steps such as; saying “hi”, sharing a toy, taking turns and saying “goodbye”. Success is then measured by direct observation from parents and therapist. Measurements are recorded day to day and then week to week. When progress is made and goals are met, more difficult goals are set. If sufficient progress is not made, adjustments are made and new goals are set.
Who provides traditional ABA or DTT and what does the structure of sessions look like?
A board certified behavior analyst specializing in autism will write, implement and monitor the child’s individualized program. Individual therapists, often called “trainers,” (not necessarily board certified) will work directly with the child on a day-today basis. Sessions are typically 2 to 3 hours long, consisting of short periods of structured time devoted to a task, usually lasting 3 to 5 minutes. 10 to 15 minute breaks are often taken at the end of every hour. Free play and breaks are used for incidental teaching or practicing skills in new environments. Done correctly, ABA and DTT interventions are not a “one size fits all” approach but every aspect of intervention is customized to each learner’s skills,
To find more information on ABA go to:
PIVOTAL RESPONSE TREATMENT
Pivotal Response Treatment (PRT) was developed in the 1970’s. PVT is a child directed behavioral intervention model also based on the principles of ABA. Pivotal Response Treatment (PRT) is one of the most studied and researched based behavioral treatments for autism. It is driven by play therapy and the treatment goals include language and speech, positive social behaviors, and a decrease in self-stimulatory behaviors (stimming). PRT is most successful when those who spend the most time with the child use PRT principles consistently. Families using PRT often state “PRT is not a therapy, it’s our lifestyle.”
Rather than target specific behaviors like ABA and DTT, PRT targets “pivotal” areas of a child’s development. These areas include self-management, social awareness, communication and social interactions. The treatment philosophy targets these critical areas in order to produce broad behavioral improvements across other areas of sociability, communication, and behavior and academic skill building. PRT is most often used with preschool and elementary aged children, but may also be appropriate for older children based on their functioning level. The child determines which games will be played during the session and which toys will be used in a PRT exchange. PRT is used to teach language, decrease disruptive/self-stimulatory behaviors, and increase social communication. Motivational strategies (what motivates your child) are used as often as possible during the program. This includes teaching your child new tasks and behaviors, praising them for trying, continued praise towards mastery and then finally intermittent checking to ensure your child retains the new skills.
Motivation strategies are a key component of PRT and stress the importance of “natural” rewards and consequences not “tokens” like those provided in ABA. This technique can be very effective when combined with the skill of Preventive Teaching.
Your child is an equal partner when developing new activities to practice new behaviors as well as choosing his/her own rewards. Here’s an example…
Your child attempts to ask to play video games, instead of providing the child a sticker for asking, or a small treat for saying please, the child is awarded with playing video games. The reward of the video game is what the child wants in the moment and he is more likely to ask again next time based on receiving the “natural” reward this time.
Who provides PRT and what am I signing up for?
PRT may be offered by school psychologists, special education teachers, and other mental health providers. The Koegel Autism Center offers a PRT Certification program.
Each treatment plan is designed to meet the goals and needs of the child, and also to fit into the family routines. A session typically involves six segments during which language, play, and social skills are targeted in both structured and unstructured play. Sessions may change as the child becomes more advanced or if a new need develops. PRT programs usually involve 25 or more hours per week. Everyone involved in the child’s life is encouraged to use PRT methods consistently in every part of the child’s life.
Where can I find more information on PRT?
EARLY START DENVER MODEL
The Early Start Denver Model (ESDM) is a developmental, relationship-based approach that utilizes techniques founded in ABA. ESDM is the only early intervention approach that has been validated by a clinical research study. ESDM is appropriate for children with autism or autism symptoms who are as young as 12 months of age, through preschool age. The curriculum is decided by the outcome of an comprehensive assessment (ESDM Curriculum Checklist) which covers: cognitive skills, language, social behavior, imitation, fine and gross motor skills, self-help skills and adaptive behavior. Professionals using ESDM focus on increasing the length of the child’s attention, identifying the child’s source of motivation, facilitating joint play therapy activities, and developing nonverbal and verbal communication. Research suggests that ESDM has been shown to increase IQ, language, social skills, and adaptive behavior when used consistently for at least one year.
Who provides ESDM and what do sessions look like?
ESDM can be provided by ESDM-trained behavior analysts, special education teachers, speech therapists and other providers. Parents can also be taught to use ESDM strategies.
ESDM programs usually involve 20-25 or more hours per week of scheduled therapy. Families are encouraged to use ESDM strategies in their daily lives. ESDM is designed to be highly engaging and enjoyable for the child, while skills are systematically taught within a naturalistic, play-based interaction. Some skills are taught on the floor during interactive play while others are taught at the table, focusing on more structured activities. As the child develops social skills, peers or siblings are included in the therapy session to promote peer relationships. ESDM can be delivered in the home, the clinic, or a birth-to-three or developmental preschool setting.
Psychologists Sally Rogers, Ph.D., and Geraldine Dawson, Ph.D., developed the Early Start Denver Model as an early-age extension of the Denver Model.
Its core features include the following:
- Naturalistic applied behavioral analytic strategies
- Sensitive to normal developmental sequence
- Deep parental involvement
- Focus on interpersonal exchange and positive affect
- Shared engagement with joint activities
- Language and communication taught inside a positive, affect-based relationship
It has been found to be effective for children with autism spectrum disorder (ASD) across a wide range of learning styles and abilities. Children with more significant learning challenges were found to benefit from the program as much as children without such learning challenges.
Who is qualified to provide ESDM?
An ESDM therapist may be a psychologist, behaviorist, occupational therapist, speech and language pathologist, early intervention specialist or developmental pediatrician. What’s important is that they have ESDM training and certification. For a list of certified ESDM providers, click here. By using an ESDM qualified provider it ensures that the professional has the knowledge and skills to successfully use the teaching strategies with children with autism.
RECENT PUBLISHED RESEARCH SUPPORTS PARENT MASSAGE
Qigong Sensory Massage is a research-based, parent-delivered massage that helps children with autism and sensory integration disorders. The evidence shows that children who receive the massage 15 minutes a day from their parents over a 5 month period demonstrate:
- improvement in mood (fewer tantrums, lessened anxiety)
- lessened sensitivity to touch
- greater ease with transitions
- improved in sleep
- improved digestion
Parents also self-report that stress also declines significantly over the same five month treatment period.
Due to the autonomic nervous system being out of balance, children with ASD tend to struggle with self-regulation, sleep, digestion, tantrums and aggression. There is also an elevated sensitivity to physical touch. Research suggests that after 10 months of regular Qijong massage treatment, sensory and behavioral problems decrease while social and self-help skills increase.
Initially, children may resist touch on several areas as they are the areas of most severe sensitivity e.g. ears, fingers and toes. Qijong massage does not avoid these areas. These areas need the most treatment. The QST autism massage protocol has specific techniques for each area of difficulty. As parents adapt the technique to their children’s responses, children can work through the sensitivity and their exposure to touch normalizes. Parents can be supported by a trained QST therapist, who delivers the massage 1-2 times a week over part of the treatment period. For children with severe autism, support from a trained therapist is recommended.
Training programs for parents have been developed that give parents the core skills and provide weekly support until the initial difficulties are overcome and the massage is fully integrated into the daily routine. Parent training is provided by trained QST therapists, and weekly support is continued for a period of four to five months during home or office visits. Treatment is continued for at least a year on a less intensive schedule. Regular contact with QST therapists helps to keep the massage in the daily routine. There are any number of reasons why the massage can fall out of the daily routine. This must be avoided, as results show that when massage is given less that 3 times a week, treatment is far less effective than when it is given 6-7 days a week.
Dr. Louisa Silva, the leading researcher of QST, has published 14 research studies on QST over a 12 year period. The video below summarizes the research completed as of 2011.
Read more on the research. The obstacle that parents face is finding a certified QST provider. This is a much more recent treatment option and is relatively new. Due to the more recent development and research completed with this treatment option there are fewer providers. Find a QST provider in your area.
Closing Comments: This complicated decision does not have to be a game of chance. I interviewed a couple tonight and they said something that stuck with me that I’ll be sure to use when working with families.
“If you’ve met one child with Autism, you’ve met ONE child with Autism. Understand that each child is unique and displays their own mixed bag of potpourri ASD symptoms.” So true.
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Jesse Heaton is a Mental Health Therapist who has worked with children and families for the last 12 years. Jesse has worked in several different treatment settings including detention programs, treatment homes, recovery centers and an Autism Spectrum long term care facility. Jesse is a parent of three children and a member of the Smarter Parenting Team.