8 - early autism interventions

what are early autism interventions?

• take place in childhood, with children up to 6 y/o

• greater family involvement and targets an array of aspects such as social communication and life skills, different goals overall to adult interventions

what early provisions are there?

• nhs

• local authority

• charity support

• private

• different provisions target different domains

what does Wolf suggest are the goals of social validity in early interventions

• social significance of intervention goals (goal is good)

• social acceptability of intervention procedures (methods are ethical and acceptable)

• the social importance of effects (we don’t accidentally harm children in the process)

what goals might the medical model of disability propose for early interventions

autism defined as behaviour, goals focused on normalisation - ‘prerequisites’ for further learning and skills, looking less autistic to facilitate socialisation and social skills

• teaching eye contact, reducing stimming, reducing echolalia, ‘proper play’

what goals might the social model of disability propose for early interventions

autistic people might communicate and learn differently (gestalt langauage processing), more to friendship than ‘behaving normally’, authentic expression is important, can make the environment more suitable for the child.

• more suitable goals supported by the autistic community

what are common goals chosen by autistic people

• top 3; quality of life/wellbeing, support and accessibility, safety (reducing aggression and self harm)

• slightly below: self-help, emotional skills, communication, social problem-solving

• middle: participation in routine, motor skills, rules of interaction and conversation. academic skills

• low: sensory tolerance, play, eye contact, reducing stimming, reducing special interest

what are important methods to keep in mind when employing support

• autonomy and self-determination

• mindless compliance - may be dangerous to individual in the future

what are adverse effects of behavioural studies?

studies asking for people’s experience and community discuss negative effects from behavioural interventions for some/many autistic people - compared to intervention studies where few limitations are mentioned

what type of demographics often appear in intervention studies

• adults responding are usually white, female or non-binary, with higher education and relatively lower support needs and are diagnosed in adulthood

• children who receive interventions are usually boys, identified or diagnosed early and usually have higher support needs or learning disability.

outline behaviourism

based on B.F Skinner’s operant conditioning, works with and focuses on observable behaviour, uses reinforcement (rewards and punishments) to increase or decrease behaviours

antecent - behaviour - consequence

Who is Ole Ivar Lovaas (1927-2010)

• founded ABA (applied behaviour analysis), most people were considered beyond help.

• one boy who was ignored when he cried stopped crying which was seen as an improvement, but obviously wasnt

• ABA to such an extreme extent stopped in the 1980s as it was inhumane

• many ‘achieved normal intellectual and educational functioning’

how did ABA change

• ~1980s physical punishments became less frequent, methods softened.

• Naturalistic Developmental Behavioural Interventions - combined developmental and behavioural methods

what traits does modern ABA have

• targets observable behaviours

• can target a wide range of goals, including autism traits, daily life skills, safety, communication etc.

• often adult-led

• often intensive: several times a week for hours

• mostly delivered by professionals

not frequently practised in the UK

What is discrete trial training

• structured, adult-led intervention

• shapes behaviour using small, discrete components that are taught through repeated trials

• 5 stages - instead of punishment, gentle guidance

evidence for ABA

Gitimoghaddam et al. 2022 - a meta-analysis for ABA intervention

• positive improvements in cognition, language development, social skills and communication, adaptive behaviour and reductions in problem behaviour

HOWEVER:

• mostly case studies

• 64% of the studies recorded 3 or less pps

• only behaviour-specific improvements vs overall skills, functionns or behaviours

what are wider concerns re: the evidence for ABA

• conficts of interest

• potential negative effects are not measured

• goals are not neuro affirmative

• little consideration for internal processes

• extremely intensive

• negative accounts in qualitative studies and community experience

what is the developmental approach (PACT)

• developmental psychology - vygotsky

• skill acquisition is built on the child’s active, self-directed engagement with a stimulating physical and social environment

• zone of proximal development, scaffolding

what is paediatric autism communication therapy

• child social communication therapy

• enhances communication between children and caregivers, increasing parental sensitivity

• work not directly with child, but changes their context

how is PACT used, and what techniques does it employ

• suitable for children ages 2-11, mostly with language difficulties

• available face-to-face or online

• therapist sessions ~1-2 hours working with families

• 30 min daily practise

• techniques include: imitation, animation, intentional communication, modelling/labelling, language expansion, routines (stories, songs, anticipation games) following the childs lead

evidence for PACT

• randomised control trial - 152 children half recieved intervention

• 2 hours a week for 6 months

• small reduction of ‘autism traits’ in PACT group

• increased synchrony, child initiations and shared attention in parent-child interactions

• small effects on language and social communication

• longitudinal follow-up also showed reduction in ‘autism triats’ due to increased social communication and fewer restricted and repetitive behaviours

critique for PACT

• some elements of original evidence outdated

• intervention and outcomes not always aligned ‘autism traits’

• not effective for all outcomes

• child perspective not always included and high parental load

parental views on PACT

• some practical challenges including sessions being too long

• video feedback helped find drawbacks

• most were very happy with process