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Tuesday 29 Jul 2014

Early Intervention

How early should we start intervention?

To put it simply, intervention should start as early as possible. When parents begin to notice their child is not developing as expected and they voice these concerns, a common response is “They’ll grow out of it, just wait”. Unfortunately, the longer you wait the more difficulty you and your child may have. If you are concerned about your child’s development, whether its their communication, social skills or behaviors, then you should begin seeking information and assistance as soon as you can.

The earlier a problem is identified, the earlier intervention can begin, and the more likely your child is to learn the skills they need to communicate, engage in social interactions and manage their behavior. If you’re still waiting for an official diagnosis, you shouldn’t be waiting to start intervention. If you think there is something that needs to be addressed, get the information, services and training you need to address it.

Why start intervention so early?

Research shows that children who receive intensive early intervention services are more likely to have improved long-term outcomes. These services can maximize their learning potential by addressing communication, play, problem behaviors and overall skill development from a very early age. We know, through extensive brain research, that neural plasticity (the brains ability to learn new skills) decreases with age. When children are very young their neural plasticity is high, but as they get older it decreases. When this plasticity decrease, it becomes more difficult to learn new skills.

This is not to say that individuals with autism are not able to learn skills if intervention is not started by a certain age. Their brains, just like everyone elses, are capable of learning and using new skills and information at any time. Behaviorally speaking, however, as we all age and grow the skills we have learned which are effective and efficient will be more difficult to change due to a longer history of reinforcement. So the earlier we intervene to address an individual’s difficulties with communication, social interactions and problem behaviors the more likely we are to elicit quick and positive change.

This quote from the book “Overcoming Autism” by Lynn Koegel and Claire LaZebnik best reiterates this point:

I can’t stress strongly enough the importance of diving into action immediately. Every expert in the field agrees that early intervention is essential and critical. The “wait and see” approach is detrimental to your child. Children with autism tend to avoid things that are difficult, and communication is difficult for them, so they avoid situations where they might be expected to communicate. As a result, they become more isolated and withdrawn. So it’s critical that you get a program started right way.

How much intervention should my child receive?

Research suggests that children should receive 25-40 hours of intensive early intervention per week. While this may seem like an extraordinary amount of time for a child, this intensity of intervention has been shown to be the most effective in addressing the needs of children. Intervention hours may be provided by ABA therapists, speech therapists, occupational therapists, parents or other family members (after receiving training on intervention implementation) or other service providers. In an ideal situation, intervention procedures should be implemented throughout the day, across settings and across people with whom the child interacts. This intensity and consistency of intervention can help catapult a child to success.

What are the goals of early intervention?

The basic goals that should be addressed with early intervention are child engagement, independence, functional spontaneous communication, cognitive skill development, social competence, play skill development, generalization of skills, and proactive approaches to problem behavior. The specific goals for intervention will be based on the child’s chronological age, developmental level, specific strengths and weaknesses, and the needs or priorities of their family.

What interventions are available and most effective?

There is no single treatment protocol for all children with autism, but most individuals respond best to highly structured behavioral programs. The National Institute of Child Health and Human Development lists Applied Behavior Analysis among the recommended treatment methods for autism spectrum disorders. Some of the most common interventions are Applied Behavior Analysis (ABA), Speech and Language Therapy, Occupational Therapy, PECS, AAC, Sensory Integration Therapy and the school-based TEAACH method.

  • Applied Behavior Analysis (ABA)
  • Behavior analysis is a natural science of behavior that was originally described by B.F. Skinner in the 1930′s. The principles and methods of behavior analysis have been applied effectively in many arenas. For example, methods that use the principle of positive reinforcement to strengthen a behavior by arranging for it to be followed by something of value have been used to develop a wide range of skills in learners with and without disabilities.

    Since the early 1960′s, hundreds of behavior analysts have used positive reinforcement and other principles to build communication, play, social, academic, self-care, work, and community living skills and to reduce problem behaviors in learners with autism of all ages. Some ABA techniques involve instruction that is directed by adults in highly structured fashion, while others make use of the learner’s natural interests and follow his or her initiations. Still others teach skills in the context of ongoing activities. All skills are broken down into small steps or components, and learners are provided many repeated opportunities to learn and practice skills in a variety of settings, with abundant positive reinforcement. The goals of intervention as well as the specific types of instructions and reinforcers used are customized to the strengths and needs of the individual learner. Performance is measured continuously by direct observation, and intervention is modified if the data show that the learner is not making satisfactory progress.

    Regardless of the age of the learner with autism, the goal of ABA intervention is to enable him or her to function as independently and successfully as possible in a variety of environments.

  • Speech and Language Therapy (SLT)
  • The communications problems of individuals with autism vary to some degree and may depend on the intellectual and social development of the individual. Some may be completely unable to speak whereas others have well-developed vocabularies and can speak at length on topics that interest them. Any attempt at therapy must begin with an individual assessment of the child’s language abilities by a trained speech and language pathologist.

    Though some individuals with autism have little or no problem with the pronunciation of words, most have difficulty effectively using language. Even those children who have no articulation problems exhibit difficulties in the pragmatic use of language such as knowing what to say, how to say it, and when to say it as well as how to interact socially with people. Many who speak often say things that have no content or information. Others repeat verbatim what they have heard (echolalia) or repeat irrelevant scripts they have memorized. Some individuals with autism speak in a high-pitched voice or use robotic sounding speech.

    Two pre-skills for language development are joint attention and social initiation. Joint attention involves an eye gaze and referential gestures such as pointing, showing and giving. Children with autism lack social initiation such as questioning, make fewer utterance and fail to use language as a means of social initiation. Though no one treatment is found to successfully improve communication, the best treatment begins early during the preschool years, is individually tailored, and involves parents along with professionals. The goal is always to improve useful communication. For some verbal communication is realistic, for others gestured communication or communication through a symbol system such as picture boards can be attempted. Periodic evaluations must be made to find the best approaches and to reestablish goals for the individual child.

  • Occupational Therapy (OT)
  • Occupational Therapy can benefit a person with autism by attempting to improve the quality of life for the individual. The aim is to maintain, improve, or introduce skills that allow an individual to participate as independently as possible in meaningful life activities. Coping skills, fine motor skills, play skills, self help skills, and socialization are all targeted areas to be addressed.

    Through occupational therapy methods, a person with autism can be aided both at home and within the school setting by teaching activities including dressing, feeding, toilet training, grooming, social skills, fine motor and visual skills that assist in writing and scissor use, gross motor coordination to help the individual ride a bike or walk properly, and visual perceptual skills needed for reading and writing.

    Occupational therapy is usually part of a collaborative effort of medical and educational professionals, as well as parents and other family members. Through such collaboration a person with autism can move towards the appropriate social, play and learning skills needed to function successfully in everyday life.

  • Picture Exchange Communication System (PECS)
  • PECS is a type of augmentative and alternative communication technique where individuals with little or no verbal ability learn to communicate using picture cards. Children use these pictures to “vocalize” a desire, observation, or feeling. These pictures can be purchased in a manualized book, or they can be made at home using images from newspapers, magazines or other books. Since some people with autism tend to learn visually, this type of communication technique has been shown to be effective at improving independent communication skills, leading in some cases to gains in spoken language.

    A formalized training program is offered through a company called Pyramid Products, and this program takes the caregiver and child through different phases. However, this manual is not the only source of training and resources. Images may be obtained through magazines, photos, or other media. In Phase one, a communication trainer works with the child and their caregivers to help decide which images would be most motivating. For example, images food may elicit the strongest response. Cards are then created (or provided through a pre-made book) with those images, and the trainer and the caregiver work with the child to help him or her discover that, by handing over the card, they can get the desired object. In Phase two, the caregiver then moves farther away from the child when showing the picture, so that the child must actually come over and hand over the card to receive the food reward. This process engages the child’s ability to seek and obtain another person’s attention. In this way, a full vocabulary and methods for using these new words are taught to the affected individual.

    In later phases, children are given more than one image so that they must decide which to use when requesting an item, and throughout the process the number of cards grows and thus the child’s ‘vocabulary’ also increases. Over time, the child may develop the ability to use sentences, including phrases like “I want” to start off the sentence, and even use descriptors like “large” or “red”. Throughout the process, which may take weeks, months or years, the caregiver gives constant feedback to the child. It is thought that by allowing children to express themselves non-verbally, the children are less frustrated and non-desirable behavior including tantrums is reduced.

  • Alternative and Augmentative Communication (AAC)
  • AAC includes all forms of communication that are used to express thoughts, needs, wants, and ideas. Everyone uses these communication strategies when we make facial expressions or gestures, point to pictures, or write. People with severe speech or language problems may use AAC strategies to supplement existing speech or replace speech that is not functional. Special augmentative aids, such as picture and symbol communication boards and electronic devices, are available to help people express themselves. This may increase social interaction, school/work performance, and feelings of self-worth.

    AAC users should not stop using speech if they are able to do so. The AAC aids and devices are used to enhance their communication, not to replace or inhibit their existing skills. These tools are available to help people express themselves. This may increase social interaction with others, support academic performance, and enhance feelings of self-worth.

  • Sensory Integration Therapy (SIT)
  • Sensory Integration is the process through which the brain organizes and interprets external stimuli such as movement, touch, smell, sight and sound. Individuals with autism often exhibit symptoms of Sensory Integration Dysfunction (SID) making it difficult for them to process information brought in through the senses. Children can have mild, moderate or severe SID deficits manifesting in either increased (hypersensitivity) or decreased (hyposensitivity) to touch, sound, movement, etc. For example, a hypersensitive child may avoid being touched whereas a hyposensitive child will seek the stimulation of feeling objects and may enjoy being in tight places.

    The goal of Sensory Integration Therapy is to facilitate the development of the nervous system’s ability to process sensory input in a more typical way. Through integration the brain pulls together sensory messages and forms coherent information upon which to act. SIT uses neurosensory and neuromotor exercises to improve the brain’s ability to repair itself. When successful, it can improve attention, concentration, listening, comprehension, balance, coordination and impulse control in some children.

    The evaluation and treatment of basic sensory integrative processes in individuals with autism are usually performed by an occupational and/or physical therapist. A specific program will be planned to provide sensory stimulation to the child, often in conjunction with purposeful muscle activities, to improve how the brain processes and organizes sensory information. The therapy often requires activities that consist of full body movements utilizing different types of equipment. It is believed that SIT does not teach higher-level skills, but enhances the sensory processing abilities thus allowing the child to acquire them.

  • TEACCH
  • TEACCH (Training and Education of Autistic and Related Communication Handicapped Children) is a special education program that is tailored to the child’s individual needs based on general guidelines. It dates back to the 1960′s when doctors Eric Schopler, R.J. Reichler and Ms Margaret Lansing were working with children with autism and constructed a means to gain control of the teaching setup so that independence could be fostered in the children. What makes the TEACCH approach unique is that the focus is on the design of the physical, social and communicating environment. The environment is structured to accommodate the difficulties a child with autism has while training them to perform in acceptable and appropriate ways.

    Building on the fact that individuals with autism are often visual learners, TEACCH brings visual clarity to the learning process in order to build receptiveness, understanding, organization and independence. The children work in a highly structured environment which may include physical organization of furniture, clearly delineated activity areas, picture-based schedules and work systems, and instructional clarity.

    It is believed that structure for individuals with autism provides a strong base and framework for learning. Though TEACCH does not specifically focus on social and communication skills as fully as other therapies it can be used along with such therapies to make them more effective.

How do I know if an intervention is effective?

The only way to know for certain an intervention is effective is to see the data. These data should be collected and reported to you as a parent on a frequent basis. If there is no data to support the efficacy of the intervention, then you are right to question whether or not the intervention should continue. Data provide us the capability to make timely decisions about interventions. For instance, if the data show the child is not making significant improvements in the expected time frame, we might consider changing something about the intervention. If, on the other hand, the data show the child is making the expected gains we know we’re on the right track. If interventionists are not collecting data, there is no way to quantify change and there is no way to make informed decisions about the efficacy of the interventions being used.

How involved should I be in my child’s intervention?

Your participation is vital to your child’s success. This may seem like a bold statement, but the truth is that if you are not involved in your child’s therapy programs the likelihood of success is much lower. This is because when you are involved in the development and implementation of interventions the intervention procedures are more likely to be used across contexts and people and your child is likely to learn and use skills more quickly. If, on the other hand, teachers and therapists develop and implement interventions but these interventions are not supported or implemented at home the skills are likely to be learned slower and the likelihood of them having long term benefit is going to be small.

As parents, you are the people who spend the most amount of time with your child. You should be integrally involved in the development of interventions, and you should receive extensive training from the professionals who work with your child so you also know how to implement the interventions well. Don’t settle for a simplified explanation of the intervention plan with no hands-on training. The professionals working with your child should be showing you and teaching you how to work with your child. This doesn’t happen as much as it should and this can be detrimental to the progress of your child. It is important that you really know how to implement the intervention so you can support what the therapists working with your child are doing and help your child generalize the skills they are learning.

How can we afford intervention services?

Without a doubt, intervention services can be extremely costly. Don’t let the cost hold you back from seeking out services, because there are also funding sources out there which can help you afford these important early intervention services. The first funding source is the Department of Developmental Disabilities (DDD). The actual structure within each state varies, but every state has a funding source to support children with disabilities and help pay for services such as respite care, ABA therapy, speech therapy, occupational therapy and physical therapy.

Another funding source for services in some states is through insurance. Currently there are 29 states which have enacted autism insurance laws which mandate insurance coverage for services. There are some exceptions to the mandate even within states (i.e. depends on where insurance is underwritten), but for the most part these additions are an amazing asset to families so they can afford services for their children.

Resources: www.autismspeaks.org