Autism Spectrum Disorder (ASD) is a severe developmental disorder which begins at birth or the first two-and a half years of life and persists for the entire life of the individual. (1) Roughly 1 in 166 American children born today will fall somewhere on the autism spectrum. That's double the rate of 10 years ago and 10 times the estimated incidence a generation ago.(6)
The increasing incidence of ASD shows that ASD is a very severe problem in America as well as the whole world. Therefore, I feel that it is important to have an effective treatment which is able to relieve the symptoms of this disorder so that the quality of lives of ASD individuals and people related to them would be improved. In this report, I am going to discuss a possible solution for this problem.
A Possible Solution
Applied Behavioral Analysis (ABA)
ABA is a type of early behavior intervention. ABA aims to improve socially significant behaviors while decreasing negative behaviors. "Socially significant behaviors" may include reading, academics, social skills, communication and adaptive living skills. (2) ABA encompasses the development of every aspect of ASD individuals besides relieving the symptoms of this disorder.
ABA is applied trough the A-B-C (Antecedent-Behavior-Consequence) approach.(3,4) ABA is conducted in playrooms specially designed at home. Each session of ABA is made as fun as possible by engaging the ASD individual with positive social relationship such as having good eye contact and frequent physical interaction so that they are motivated to learn.
Figure 1: on the left: Parents make eye contacts with their children; on the right: A playroom
especially designed for autistic children adamsonrise.com/page8.htm (9)
The procedure of ABA is shown in the flow chart below.
Structuring learning environment
Enhancing motivation for learning
Figure 2 Teaching procedures of ABA- The Antecedent-Behavior-Consequent (A-B-C) approach
ABA 2000 Workshop Program, Jun-ichi Yamamoto, PhD, University of Tsukuba
There is a written program or set of instructions for teaching each skill which is designed by a behaviour analyst specifically based on the ASD individual's abilities and needs. One new skill or behaviour is targeted at one time and the whole A-B-C procedure is repeated until the skill is mastered before changing the target.
Assistances are given to the ASD individual after the instruction only if he is unable to respond appropriately. These are gradually removed as the procedure is repeated so that the behavior will eventually occur simply to a request or some other appropriate cue. (3) At the end of each session, desirable behaviors are reinforced by giving rewards such as sweets, chocolates, a hug and a smile. Meanwhile, maladaptive behaviors(such as stereotypic behavior, self injury, aggressive and disruptive behavior)(7) are not reinforced, corrected and eradicated. (4)
The learner's progress is measured and assessed frequently. Data collected when every respond is given are reviewed regularly by the behavior analyst directing the programming so that learning errors can be caught early and intervention methods adjusted if progress is not satisfactory.
Below is an example of how a trained person practises conversation skills with an ASD child: (10)
Teacher : Hi, Alex, are you excited about Christmas?
A : [no response]
Teacher : Are you excited about Christmas? Say, Yeah, I want to open my...
A : Yeah, I want to open my presents!
Teacher : [Smile] Me too! What presents did you ask for?
A : I asked for presents.
Teacher : What presents did you ask for? Say, For Christmas, I asked for...
A : I asked for a bike. For Christmas.
Teacher : Cool! [tickle]
Effectiveness of ABA
Applied Behavioral therapy (ABA) can be effective and appropriate in helping ASD patients lead normal lives because it helps them develop normal intelligence, social skills and reduce disruptive behaviors.
The effectiveness of ABA can be proved by a small study conducted by Ivar Lovaas at the University of California, Los Angeles in 1987.
9 out of 19 autistic children taught for 40 hours a week with behaviourist methods had big jumps in IQ and were able to pass first grade; only 1 out of 40 in control groups did so.
This quote is cited from an article entitled "New Insights into the Hidden World of Autism" in TIMES magazine, published on May 29 2006 (2). It is very reliable and factual source as this magazine is very reputable and well-established with a significantly large number of readers world-wide. The articles in it are written by experts from that particular field concerned and reviewed by other professionals of the same field beforehand to ensure the information provided by the article are valid. Furthermore, the results of the same study found from other sources (2, 11,12) agree with it.
However, this study can be considered outdated as it was conducted more than 10 years ago. Nevertheless, results of this study are supported by another study: Sallows and Graupner (2005) sought to replicate Lovaas' procedures, with the exception of providing aversive consequences for severe problem behavior.
It was found that all children made substantial gains in IQ score. After 2-3 years of treatment, 48% were receiving services in their home school district. The authors also found that a positive treatment outcome was best predicted by a child's pre-intervention language, imitation, and social skills.(11)
Besides that, ABA has been proven to be more effective in treating autistic children than generic early intervention and "electric" treatment (incorporation of many different techniques used to treat ASD) by Howard, Sparkman, Cohen, Green, & Stanislaw (2005).It was found that, after over a year, children treated with intensive behavioral treatment had gained substantially more skills while the children who undergo the other two treatments did not produce the substantial increases in communication skills observed with the intensive behavior analytic intervention.
Although the effectiveness of ABA in treating ASD individuals have been proven (2,7,13-15), the outcomes of ABA are affected by intensity of treatment, age of children receiving treatment and the professionalism of therapists. A research conducted by The Centre for Autism and Related Disorders found that a higher intensity of ABA treatment at a younger age leads to faster learning.(13)
Figure 3 Graph of mean mastered behavioral objectives per month against average treatment hours per month for two different age groups shows that an increase in treatment hours and a decrease in child age increases skills acquired per month. (13)
Therefore, under ideal conditions, ABA is shown to be the most effective in treating ASD.
Economical and Social Implication
Individuals with ASD require great adherence to therapy sessions which would cause huge financial burden and economic impact. ASD individuals require continuous and long hours of ABA therapy sessions every week for years. The cost of enrolling ASD children into schoolsÂ specialize inÂ ABAÂ treatment can be quite high; tuition ranges from $16,000 to $25,000 per year. Home-based ABA treatmentÂ usingÂ therapistsÂ in training orÂ college students who have taken a workshop in theÂ ABA approach costs $5,000 to $20,000/year. A qualified, full-time (30 hours/week or more)Â ABAÂ therapistÂ costs approximately $30,000 to $50,000 per year. (12) ASD individuals from middle-class or poor families may not be able to afford these expensive treatments and consequently they may be left untreated.
A social issue which arises is there is very high demand forÂ ABA-trainedÂ therapists. This is because the therapy is conducted on a 1 on 1 basis for long hours every day and so it may be difficult to find one who is available. Furthermore, there is a lack of schools providing ABA treatment, causing a substantial number of ASD children enable to get the treatment they need.
A typical example of both economical and social implication is South Africa. In south Africa, there are only 9 schools for children with autism. An estimated 135 000 autistic children are not getting the specialised education they need and a lot of these children are kept at home, are hidden away from society and they don't benefit at all. Parents are frustrated and don't know what to do, where to go. (16)
Therefore, I feel that governments should channel more funding to establish more centers or schools which provide free programs based on ABA, as well as training more ABA therapists. Schools may also offer scholarships toÂ parentsÂ in need.(12)
Benefits and Risks
Besides reducing disruptive behaviours while helping ASD individuals develop normal behaviours, ABA also improves the quality of lives of the family members of ASD individuals. When autistic children can gradually change to match their peers, their family members especially parents will feel relieved. Besides that, with increasing number of evidence on the efficacy of ABA and direct involvement of parents in their children's therapy sessions, parents start to see hope and gain control over their children's behaviour.
80% of parents reported levels of stress above the 85th percentile are parents in the general population, regardless of educational program. It was found that parents of children with autism participating in traditional school-based programs on average reported higher levels of overall stress and stress related to child characteristics than parents of children in ABA programs. (18)
Harold Longenecker, Ph.D. Parental stress - ABA and traditional special education programs
The major drawback of ABA is the long hours of therapy session (40 hours per week). It is too strenuous for children. Besides that, ABA also has a bad reputation of creating robotic children as a result of incompetent therapist just implementing the procedure without knowing the importance of generalizing the acquired skills and behaviours to the natural environments. Without this, autistic children are unable to adapt and respond to the ever-changing real world. (12) In my opinion, parents should plan their own children's daily schedule and allow breaks after a certain period of therapy for their children to rest. Parents themselves should also become behaviour therapists of their own children by attending courses on ABA so that they can make their children practise their acquired skills whenever possible and help integrate their skills into their lives.(17)
When Jake was being taught to wave bye-bye, we would make sure to prompt him to use this skill whenever the situation arose; when someone was leaving the house or the park. Sometimes we would create opportunities. (17)
Karen Siff, an autistic child's (Jake) mother
Medication treatment is another possible treatment for ASD. The common medicine given to ASD individuals are typical anti-psychotics, atypical anti-psychotics, serotonin reuptake inhibitors, beta blockers, anti-convulsant medications, naltrexone, secretin and stimulants. These drugs are mainly used to treat or manage the symptoms and associated conditions of ASD such as aggression, agitation, hyperactivity, impulsive behaviors, inattention, irritability, repetitive motor behaviors and self-injury which significantly interfere with daily functioning.
Psychopharmacologic research (19) in ASD is punctuated by initial case reports and open studies that demonstrate dramatic treatment benefits. However, when these treatments have been examined more rigorously, the benefits appear much more modest and often cannot be substantiated in randomized controlled trials. The best treatment seems to work in only 50-60% of participants. Moreover, these medications may bring about considerable side effects.(20). These data are obtained from A Review of the Research to Identify the Most Effective Models of Best Practice in the Management of Children with Autism Spectrum Disorders. This source is reliable and factual because this review is a compilation of various researches, case studies and programs from many sources to make a comprehensive overview about all the available treatments of ASD. Besides that, this review is published by Department of Ageing, Disability and Home Care, University of Sydney, a non-profit organization. The writers of this review are professionals who have in depth knowledge on this field of study. However, the info about medication treatment in this review is too brief.
I feel that medication can be an effective treatment to manage the symptoms of ASD but it has to be implemented alongside with other treatments which target the development of other aspects of ASD individuals such as academics and social relationships. The dosage of each drug administered should also be monitored closely so that the side effects are still manageable.
The adverse and disruptive behaviours of some autistic individuals may be caused by inability to control their sensory system. These individuals are hypersensitive or under-sensitive to light, noise, and touch. They are unable to stand the sound of a dishwasher, or, on the other extreme, need to flap and even injure themselves to be fully aware of their bodies. (22) Sensory integration aims to help autistic individuals by addressing this problem.
Sensory integration is a form of occupational therapy and is performed by specially trained occupational therapist. (22) Each session of integration is conducted in specially equipped rooms for 2-3 hours on a 1:1 basis with the therapist carrying out a range of physical activities such as swinging a net swing, jumping on the mat which gives various sensory inputs. The outcome of these activities may be better focus, improved behavior, and even lowered anxiety.
Occupational therapy using sensory integration techniques to address sensory processing problems is commonly used in children with ASD. Although many believe occupational therapy is subjectively effective in educational and clinical settings, research data to support its effectiveness is scant.(23)
The American Association of Pediatrics
A study conducted to investigate the comparative effects of sensory-integration therapy and behavioural interventions on rates of self-injurious behavior (SIB) in a 9-year-old boy with diagnosis of autism clearly demonstrated that behavioural intervention was more effective in reducing SIB than the sensory-integration therapy. (24)
This shows that ABA is still a more effective and well substantiated method to treat ASD while sensory integration serves as a viable alternative for ASD individual with sensory problems.
(a) Book References
Autism in: The Merck's Manual of Medical Information. 2nd Home Ed.  New York (US): Merck & Co., Inc. ISBN: 0-7434-7734-0
Jacqueline M. Roberts & Greta Ridley, A Review of the Research to Identify the Most Effective Models of Best Practice in the Management of Children with Autism Spectrum Disorders.  Department of Ageing, Disability and Home Care, University of Sydney
Sicile-Kira, Adolescents on the Autism Spectrum , Great Britian, Mackays of Chattam plc
Brenda Boyd., Parenting a Child with Asperger Syndrome , Great Britian, Athenaeum Press, Gateshead, Tyne and Wear.
(b) Journals Articles
Glen O. Sallows and Tamlynn D. Graupner. Intensive Behavioural Treatment for Children with Autism: 4 year Outcome and Predictors (Novenber 2005) American Journal on Mental Retardation, Vol. 110, Number 6: 417-438
Claudie Wallis, Amy Lennard Goehner, Inside the Autistic Mind, TIME magazine, Vol. 167, No. 21, May 29, 2006
Applied Behavior Analysis for Autism, Gina Green, PhD, BCBA
San Diego State University and the University of North Texas Board of Trustees, Cambridge Center for Behavioral Studies http://www.behavior.org/autism/
Prevalence of Autism Spectrum Disorders --- Autism and Developmental Disabilities Monitoring Network, Six Sites, United States, 2000 Autism and Developmental Disabilities Monitoring Network Surveillance Year 2000 Principal Investigators, http://www.jhsph.edu/publichealthnews/articles/2007/lee_autism.html
The Centre for Autism and Related Disorder Research Team finds that a Higher Intensity of ABA Treatment at Younger Age Leads to faster Learning. http://www.centerforautism.com/autism_publications/default.asphen
First Ever Study Ever to Document Recovery in a Large Group of Children with. Autism http://www.centerforautism.com/autism_publications/default.asphen
Arizona Funded Autism Study http://www.centerforautism.com/autism_publications/default.asphen
Marita Broadstock & Carolyn Doughty. The Effectiveness of Pharmacological Therapies for Young People and Adults with Autism Spectrum Disorder (ASD). New Zealand Health Technology Assessment. http://nzhta.chmeds.ac.nz/publications/aut_disorder.pdf
Applied Behavior Analysis for Children with Autism
Published Nov 5, 2009, last updated Dec 21, 2009