Understanding Behavioral Therapy for Autism
How's a parent to manage behavioral choices for autism?
Posted Jul 06, 2016
Although there is no cure for autism, various interventions diminish the symptoms, sometimes profoundly. Since both social and communication differences are part of the diagnosis, behavioral and speech-language therapy are typically the foundation of intervention. But one challenge in planning, and a stress for parents, is that no single educational plan works for all children.
From a research point of view, the most proven approach for children with autism remains behavioral therapy. While behavioral intervention sometimes seems meant only for overly rambunctious children who act out, that’s not the case. It’s also the main tool we have to develop social skills. Just as a varsity athlete continues to work to improve even when things are going well, a behavioral therapist acts like an athletic coach in polishing your child’s social abilities.
For a parent, figuring out what approach to take with behavioral therapy can be confusing. For starters, schools frequently move children into the mainstream quite early in their schooling. While that’s always the larger goal, it may mean too soon a shift away from intensive behavioral programs that support social growth. Children who receive ongoing therapy are more likely to fall into the small number of children who outgrow the diagnosis entirely; in the short term, that can mean less time in mainstream or ‘inclusion style’ classrooms. More intervention now may mean more age-appropriate skills later, allowing an easier transition into the mainstream.
Another challenge is trying to figure out which type of behavioral therapy best matches your child. In fact, there’s no way to know exactly what will work for any individual, apart from making a logical plan, being flexible in monitoring progress, and making adjustments when needed. The research doesn’t yet say exactly how much or what type of intervention is best–only that continuing behavioral therapy has benefit.
The good thing about behavior intervention is that it is both effective and safe. The not-so-good is that it can be both labor-intensive and costly. And since behavioral therapy comes in a variety of styles, picking one may feel like a guessing game. But as a bottom line, when deciding where to put time and energy inside or outside of school, behavioral therapy remains the most proven way to develop skills in children with autism.
Common Types of Behavioral Therapy
Probably the most studied intervention for autism is applied behavior analysis (ABA), which has been around for more than 50 years. It is a highly structured, scientific approach that teaches play, communication, self-care, academic and social living skills, and can reduce problematic behaviors. There is plenty of research showing that it improves outcomes for children with autism.
The basic premise of ABA is that we can break down skills into component parts and, through repetition and reinforcement, encourage learning. The approach relies on observing a situation and adults defining what would benefit a child, even when he or she may still be focused elsewhere. For example, if a child is not interested in greeting others or toilet training, through ABA we might choose to teach them those skills anyway because we recognize their long term value.
ABA is the typical starting point for children with more severe symptoms, with a recommendation of as many as 40 hours a week (such as in a full-time, classroom-based program). It has a role for many or most children with autism, even as skills improve and they begin to make friends and improve socially.
Verbal behavior therapy is a type of applied behavior therapy that teaches non-vocal children how to communicate purposefully. In other words, it teaches why we use words—to get a desired response. For example, it’s not enough to point to a cookie so a child knows it’s a cookie—that’s simply labeling objects. Children are encouraged through repetition to use functional skills. It’s a style of therapy that helps children understand that communication produces positive results.
In a typical session, the therapist will present a series of stimuli based upon a child's identified preferences and through modeling and slowly decreasing adult prompting, cultivate more independent skills. Stimuli used are those that will attract a child’s interest—a cookie in the kitchen or a swing on the playground, for example. This therapy typically requires a minimum of three hours a week with a trained therapist carried out in a natural environment to increase functional communication.
Cognitive-behavioral therapy (CBT), which has also been around since the 1960s, is most often recommended for less impaired children. It helps with concerns common with autism, such as being overly fearful or anxious. Studies show that is can be effective in reducing challenging behaviors, such as obsessing over a specific thing or topic (numbers or cars, for example), or frequent meltdowns. CBT can also teach a child to better regulate emotions and develop impulse control.
Other behavioral models for addressing autism focus more on developing skills a child already possesses and working on their deficiencies in subtler ways. Developmental and individual differences relationship (DIR) therapy—also called floortime, for example, helps a child focus on strengths, interests, and communication skills that already exist, then builds skills following that starting point. In other words, it engages a motivated child to lead the way as the therapist catches naturally occurring moments to use as teaching moments. Relationship development intervention (RDI) is a family-centered approach designed to build relationships through sharing emotional and social novel experiences. Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) is a classroom-based program meant to individualize academic instruction and social development and adapt to a particular child’s strengths.
Various types of social skills groups help children engage in pragmatic language and manage more real-world difficulties with peers. While observational studies show them quite effective, less direct research supports their success so far. Because children with autism typically engage easier with adults, social skills groups serve a vital role in bringing out difficulties specific with other children around.
In these types of groups, a therapist can set up specific situations that mimic what often happens in real life and what behaviors are appropriate. They often mix in text and pictures as a way of demonstrating social skills. Social scripts provide children with the specific language to manage difficult, everyday situations. Social skills groups are frequently a vital intervention, although, as with much of autism management, generalizing skills from group to real life may require patience and repetition over a fairly long stretch of time.
Try With Trial and Error
Long-term planning for children with autism requires patience and diligence. Most often, behavioral therapy is not the only needed intervention, and is combined with speech-language therapy, occupational therapy, family and academic supports. Yet behavioral therapy, as time- and labor-intensive as it may be, remains the foundation of skill-building for most children with autism. For any child with autism, when skills appear behind peers or behavior remains disruptive, reconsidering the amount and type of behavioral therapy received is a fundamental first step towards a solution.
Thank you to Dr. Christine O'Rourke-Lang for her support with this post. She has been a board-certified behavior analyst for over 10 years and specializes in working with children with ADHD, autism spectrum disorder, speech and language impairments, social skill needs, and behavior management issues.