Are There Scientifically Effective Treatments for Autism? By: talesfromthespectrum.

Are There Scientifically Effective Treatments for Autism?By: talesfromthespectrum

Primer on Autism Spectrum DisordersIn 1943, Dr. Leo Kanner of the Johns Hopkins Hospital studied a group of 11 children and introduced the label of early infantile autism into the English Language.The word autism means escape from reality.

Primer on Autism Spectrum DisordersAt the same time a German scientist, Dr. Hans Asperger, described a milder form of the disorder that became known as Asperger syndrome.

Primer on Autism Spectrum DisordersThus these two disorders were described and are today listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR (fourth edition, text revision) as two of the five pervasive developmental disorders (PDD), more often referred to today as autism spectrum disorders (ASD).

Primer on Autism Spectrum DisordersAll these disorders are characterized by varying degrees of impairment in communication skills, social interactions, and restricted, repetitive and stereotyped patterns of behavior.National Institutes of Mental Health (NIMH)

Primer on Autism Spectrum DisordersThe pervasive developmental disorders, or autism spectrum disorders, range from a severe form called autistic disorder, to a milder form, Asperger syndrome. If a child has symptoms of either of these disorders, but does not meet the specific criteria for either, the diagnosis is called pervasive developmental disorder not otherwise specified (PDD-NOS).

Primer on Autism Spectrum DisordersAutism is a spectrum disorder (or condition). It helps to think of the autistic spectrum as a continuum or line ranging from very extreme abnormalities in communication and relating to others (classic autism) to much more subtle (but still serious) difficulties as in High Functioning Autism or Asperger Syndrome. The continuum extends on into the wide range of behavior patterns we think of as "a bit different" or as just variations on "normal".

Primer on Autism Spectrum DisordersWhat is Autism?-Autism is a complex developmental disability that typically appears during the first three years of life.-The result of a neurological disorder that affects the functioning of the brain, autism and its associated behaviors have been estimated to occur in as many as 1 out of 150 individuals.

Primer on Autism Spectrum Disorders-Autism is four times more prevalent in boys than girls and knows no racial, ethnic, or social boundaries.-Family income, life-style, and educational levels do not affect the chance of autisms occurrence.

Primer on Autism Spectrum Disorders-Autism interferes with the normal development of the brain in areas of social interaction and communication skills.-Children and adults with autism typically have difficulties in verbal and non-verbal communication, social interactions, and leisure or play activities.-The disorder makes it hard for them to communicate with others and relate to the outside world.

Primer on Autism Spectrum Disorders-Individuals with autism may exhibit repeated body movements ( hand flapping, rocking), unusual responses to people or attachments to objects, and they may resist changes in routines.-The Autism Society of America

Primer on Autism Spectrum DisordersLets Look at a video glossary of behaviors common for individuals with autism to exhibit!www.autismspeaks.orgLets look at the diagnostic criteria....

Before we start...There has been a lot of controversy surrounding the link between vaccines and autism.Some parents and researchers believe that either the thimerosal (a mercury based preservative that is no longer in vaccinations) or the combination of giving a vaccine containing live measles in the MMR vaccine caused or was an environmental factor that helped produce autism in children.

Vaccines and Autism...Is there a link?HOWEVER...The institute of Medicine (IOM) conducted a thorough review on the issue of a link between thimerosal and autism.A final report from the IOM, Immunization Safety Review: Vaccines and Autism, released in May 2004, stated that the committee did NOT find a link.Mercury has NOT been used in vaccines since 1999 with the exception of some flu vaccines. The MMR vaccine does not and never did contain thimerosal.The National Institute of Mental Health, 2007

Vaccines and Autism...Is there a link?Another study quoted in the article Alternative/Complementary Approaches to Treatment of Children with Autistic Spectrum Disorders (Levy, 2002) also states that the scientific evidence does not support an association at a population level between ASD and MMR.

Treatments for Autism Spectrum DisordersIt is helpful to think of all the treatments as falling into one of three categories for the sake of this discussion.Well refer to one category as biologicals another as non-biologicals, and another as comprehensive programs & communication and sensory techniques.Treatments for ASDBiologicalNon-biologicalsComprehensive Programs & communication and sensory techniques.

Treatments for Autism Spectrum DisordersBiologic agents can either can be bought over the counter by families or administered by a physician.The nonbiologic treatments are novel approaches to existing therapies that are provided by a therapist or may be self-administered by the family or child.The comprehensive program and communication and sensory techniques will include center-based methods that aim to reinforce desired behaviors and reduce inappropriate behaviors as well as therapies provided by certified therapists. This category includes...ABA, DIR, Denver Model, TEACCH, Sign Language, PECS, Sensory Integration Therapy, and Sensory Diets.

Listing of TreatmentsBiologicalNon-BiologicalComprehensive Programs / Sensory and Communication Techniques

BiologicalsLets start with biological treatments.Lets begin with Vitamin Supplements!

Vitamin SupplementsVitamin B6 and MagnesiumAny side effects?

Vitamin B6 with MagnesiumListed in the Defeat Autism Now! (DAN!) Protocol, proponents believe that taking mega-doses of vitamin B6 with magnesium to help absorption can help individuals with ASD behaviorally and communicatively.The theory behind this treatment posits that individuals with ASD have weaknesses in metabolism that reflect needs for B vitamins and other supplements.DAN! protocol states that, There is good published evidence that supplements of vitamin B6 and magnesium reduce symptoms in children with autism. (DAN! Protocol, 2002).The B6 dosage is at one to two times the Recommended Dietary Allowance.

Vitamin B6 EvidenceHowever.....only a few controlled scientific studies have shown any benefit, and those that do only show short-term benefits. Most studies refute claims of behavioral improvement, (Levy, 2002).Several studies have shown some symptomatic benefit, but are compromised by methodologic problems.Evidence to support the use of vitamin B6 as a CAM intervention for ASD is mixed and not conclusive, (Umbarger, 2007).A double-blind, placebo controlled study could not corroborate prior findings.Potential side effects include peripheral neuropathy and arrhythmia from magnesium overdose!

DMG (Dimethylglycine)Any evidence?Any side effects?

DMGDMG is a non-protein amino acid. It can bind to folic acid and reduce levels of folic acid in the body.DAN! Protocol recommends taking DMG because they have found that folic acid levels are elevated in children with autism.DAN! recommends taking 125 mg three times daily. They state that DMG will boost language performance with noticeable effects within days to weeks. (DAN! Protocol, 2002).

DMGHowever...... a small case series determined that DMG was not found to beneficial.Problems with poor methodologies and inadequate dependent variable measures have plagued any study that purports DMG as a beneficial therapy.

Vitamin A (Cod Liver Oil)Any evidence?Any side-effects?

Vitamin A (Cod Liver Oil)Vitamin A treatment is based on the assumption that some children with ASD are vulnerable to the impact of mercury exposure and that vitamin A supplementation can change this vulnerability.This is based on the hypothesis that genetically at-risk children are predisposed by G-Alpha protein defect. It is assumed by proponents of that theory that live measles vaccine depletes stores of vitamin A, resulting in metabolic changes and precipitating behavior changes in children with ASD.

Vitamin A (Cod Liver Oil)Supplementing with natural forms of vitamin like cod liver oil is purported to improve immune and visual function.However....no data is available about effectiveness.There are MULTIPLE SERIOUS side effects from overdose including increased pressure around the brain.

SecretinIncluding Alkaline Salts and BethanecolAny evidence?Any side effects?

SecretinIs a hormone found in the gastrointestinal tract that helps control digestion.It is used intravenously during upper gastrointestinal endoscopy.Its off-label use for children with ASD came to attention after publicity in 1998 on a national television show.The show highlighted a case report in the medical literature about 3 children with ASD who improved 5 weeks after secretin administration.

SecretinThese children started talking and decreased gastrointestinal symptoms as well as improved behavior.The effects wore off 6 weeks after the intravenous delivery of secretin.Since then, multiple evidence-based scientific studies have failed to confirm the claims of dramatic improvement in the symptoms.

SecretinAccording to Umbarger in his article State of the Evidence, the evidence to support the use of secretin to treat people with ASD is overwhelmingly against its efficacy as a CAM intervention.Systematic reviews of randomized controlled trials found no difference between treatment and control group.DAN! Protocol still urges parents to try it and states that , The clinical effectiveness of secretin has become more credible with a meta-analysis of the earlier negative studies, (DAN! Protocol, 2002).

SecretinDespite objective data disproving an association in their individual child, many families who participated in well-designed, double-blind controlled trials have continued using secretin. Potential side-effects include immunologic or allergic response related to repeated administration of foreign protein and seizures.

Alkaline Salts...in Lieu of SecretinSome families have explored ingestion of alkaline salts in an effort to provide natural secretion of secretin and other gastrointestinal peptides.Alkaline salts are POTENTIALLY HARMFUL to the liver. No studies of safety or efficacy have been completed, and there is the potential risk in altering the bodys natural acid-base homeostasis.

Bethanecol in lieu of secretinIs a medication used in gastrointestinal disorders such as gastroesophageal reflux.Some clinicians feel that it is a pancreatic stimulant and has an effect similar to secretin.

BethanecolOne non-peer reviewed source reports that childrens symptoms improved after treatment with a combination of vitamin A in cod liver oil and bethanecol.No published results of controlled studies are available.

Anti-ViralsInclude antivirals and intravenous immunoglobulins (IVIGs).Any evidence?Any side effects?

Theory Behind AntiviralsSome researchers have suggested that ASD might be caused by a dysfunction in the immune system.There are some reports that have found abnormalities in the number and types of antibodies, immunoglobulins, lymphoctyes, and proteins in the central nervous systems of individuals with ASD.Some posit that the effect of the MMR Vaccine is behind these findings.DAN! researchers have stated that, Measles virus is present in the intestinal lymph nodes of most children with autism who have been studied.These findings have been used to justify treatment with IVIGs or antiviral medications.

Antiviral TreatmentsDAN! Protocol states that, The family of anti-herpes medicines is the one that has had the most use in children with autism....with good results.However, even they admit that there have been no controlled studies of the use of these medicines.Although there are anecdotal reports of children treated with these medicines, there are no data on safety or efficacy. Controlled studies of IVIG treatment do not document significant improvement.The literature to date does not support the use of IVIG or antiviral treatments outside of research protocols.

AntibioticsIncludes probiotics, and medicines such as vancomycin.Any evidence?Any side effects?

Antibiotics and Probiotics...The Theory behind the treatmentIt is believed by some researchers that gastrointestinal dysfunction in children with ASD may cause an overgrowth of bacteria in the gut.The theory believes that their may be a possible yeast overgrowth, a primary dysfunction in the immune system, and antibiotic overuse that leads to the gastrointestinal problems and resulting overgrowth of bacteria.

Antibiotics and ProbioticsTherefore, treatment with probiotics has been used to replace bad bacteria in the gut with good bacteria, such as acidophilus.Treatment with the powerful antibiotic vancomycin has also been used to eliminate a large number of bacteria in the gut.

Antibiotics and ProbioticsA case report on an Internet Listserv of several children who were treated in an open label trial of vancomycin caused the interest in its use as a possible treatment for ASD.DAN! Protocol mentions a course of gentamycin and vancomycin. They discuss a dose of 160 mg of gentamycin five times daily for 3 days combined with 250 mg of vancomycin 5 times daily. They then state that, the consumption of large doses of probiotics and antifungals offer some hope of restoring a healthy flora while relieving symptoms that had been produced by a toxic bowel, (DAN! Protocol, 2002).There have been no controlled scientific studies on vancomycin and its use as a treatment for individuals with ASD.Side effects of vancomycin include colitis-like inflammation and development of resistant strains of bacteria to this antibiotic.

AntifungalsIncludes nystatin, Diflucan, and other medications.Any evidence?Any side-effects?

Theory Behind AntifungalsOne theory of causation of autism involves yeast overgrowth in the gastrointestinal tract due to the excessive treatment with antibiotics.The theory suggests that the overgrowth of candida or yeast produces toxins which act centrally on the nervous system to produce the symptoms of autism.

Theory Behind AntifungalsThere is no evidence to support this theory and the initial evidence used to formulate this hypothesis was circumstantial.Horvath et al did not demonstrate yeast in samples taken from the small intestines of children with ASD.However, some still believe in this theory and in the treatment using antifungals.

AntifungalsSide effects include liver toxicity and anemia.Anti-yeast diets have also been proposed (Dr. Crook) but these too have not been examined for efficacy in clinical trials.

Diets....Gluten-Free/Casein-Free DietAlso known as the GF/CF Diet.THIS IS A BIGGIE!!! (Thanks in part to media coverage and an overabundance of books on the subject!!!)Many families with children with ASD try this diet!Is there any evidence to support it?Any side-effects?

The Theory Behind the DietThe Opioid Excess Theory is the main reason/impetus behind the GF/CF diet.This theory posits that children with ASD have permeability of the gastrointestinal system (leaky gut syndrome).Because of holes in the gastrointestinal system, proteins in wheat (gluten) and dairy (casein) are not digested and absorbed.The theory states that these fragments of gluten and casein proteins are in the blood system and act in a way that affect brain function in a similar manner as the class of drugs known as opiates.The theory believes these proteins then cause disturbances in the brain that manifest in autism and autism symptoms.

Evidence to Support the GF/CF DietThere has been little scientific evidence to support this theory.There are difficulties in conducting studies on the GF/CF diet due to multiple confounding factors.Study problems have also included a lack of valid outcome measures and no placebo controls or challenges There are conflicting reports of laboratory studies to confirm gluten sensitivity in children with ASD.The Cochrane Collaboration also examined the effect of gluten- and casein-free diets for ASD and was unable to reach a consensus on the effectiveness of such interventions.It is listed on the NOT RECOMMENDED section of the article written by Umbarger due to lack of evidence supporting its effectiveness.

Side Effects of GF/CF DietBecause of its high media coverage, many families undertake this diet without medical and other professional guidance or nutritional support.There may be risks such as decreased calcium and vitamin D intake.It is recommended that families who are following a GF/CF or any elimination diet be monitored by primary care physicians.

ChelationMercury detoxificationAny evidence?Any side effects?

ChelationInvolves the administration of a chemical either by mouth or through an intravenous catheter of a substance for the purpose of removing from the blood heavy metals such as lead, iron, and mercury.My son used a chelation cream obtained via a prescription from an environmental and occupational doctor that was made by a compounding pharmacy.The chelation cream was rubbed on his back nightly. I was the only one allowed to administer because I dont have metal fillings and my husband did. (The stuff smells awful!)

Chelation The theory supporting chelation suggests that heavy metal intoxication, especially from mercury from.....VACCINES is responsible for the autism.The treatment does not have adequate scientific scrutiny!!!Protocols for chelation treatment in children with ASD have been proposed and are being implemented by practitioners without benefit of controlled scientific study of their efficacy for changes in symptoms of ASD. (i.e. DAN! Protocol).

ChelationStudies have not been able to confirm chelations efficacy in producing developmental changes.The chemicals used for chelation (DMSA, DMPS) are NOT approved by the FDA for treatment of autism.They are potentially DANGEROUS with side effects of liver and kidney toxicity, fluid imbalance, and even death.

ChelationUmbarger states that, Many families, eager to find a way to improve the outcomes for their child with ASD, have taken the road toward potentially dangerous interventions to try and cure ASD through chelation therapy. This has resulted in at least one death associated with chelation as an intervention for ASD.Howard Carpenter, the executive director of the Advisory Board on Autism-Related Disorders, said it was just a matter of time before there would be a death linked to the therapy. Carpenter went on to state that, Parents are so desperate. Some are willing to try anything.

Non-BiologicalsAuditory Integration Therapy (AIT)Faciliated CommunicationCraniosacral ManipulationInteractive MetronomeIrlen LensesAny evidence?Any side effects?

Auditory Integration Therapy (AIT)The goal of this therapy is to decrease sensitivity that some individuals with ASD have to sound.Proponents of AIT suggest that music can massage the middle ear, reduce hypersensitivities and improve overall auditory processing ability.Involves systematic exposure to altered music by headphones.Expensive. I was quoted a price of over $2,000 in 2003!

AIT...Evidence?The American Speech and Hearing Association (ASHA) has recommended against the use of AIT.The Cochrane Collaboration also examined evidence on the effectiveness of AIT as an intervention for ASD. Inconsistent methodologies used in these studies precluded the use of meta-analysis.Their research found that the studies indentified positive benefits, while the other failed to demonstrate any efficacy.A well designed study described in a recent position paper of the American Academy of Pediatrics did not confirm positive effects and the academy does not endorse this treatment.The National Research Council states that studies have not supported either AITs theoretical basis or the specificity of its effectiveness.

Facilitated CommunicationFC is a method for providing support to individuals with severe communication problems as they convey typed messages.Supports consist of emotional (encouragement); physical (stable physical contact, supporting the forearm or wrist, pulling back the communicators hand, helping isolate the index finger); and communicative (ignoring stereotypic behaviors and utterances, using structured questions) components to stimulate communication.

Facilitated CommunicationNot recommended by ASHA due to failure to meet scientific standards for efficacy.ASHAs position statement on FC expressed concern regarding the negative consequences from misrepresentation of message attribition. Other studies on FC also demonstrate that positive results can not be confirmed when examined in a blinded fashion and that effects seen in children have subsequently been shown to be a function of activities of the facilitator.The National Research Council states that quantitative studies reveal no validation for FC.

Craniosacral Manipulation..Irlen Lenses...Interactive MetronomeCraniosacral manipulation is a type of manipulation done by chiropractors, PTs, and OTs trained in the technique.It is said that by massaging the skull, the flow of cerebrospinal fluid is altered which affects behavioral change.No scientific treatment data are available to confirm this.

Irlen LensesA variety of visual therapies (including oculomotor exercises, colored filters, and ambient prism lenses) have been used with children with autism in attempts to improve visual processing or visual-spatial perception.Are purported to help individuals who have trouble discriminating visual stimuli due to sensitivity to lighting, colors, or color contrasts.According to the National Research Council (2001), there are no empirical studies regarding the efficacy of the use of Irlen lenses or oculomotor therapies specifically in children with autism.Furthermore according the Council, studies have not provided clear support for either its theoretical or its empirical basis.

Interactive MetronomeTheoretical Treatment.The Interactive Metronome (IM) is a computer-based assessment and training program designed to improve the brains processing abilities that affect attention, motor planning, and sequencing. No studies have been completed.

Comprehensive Programs and Communication & Sensory TechniquesThese include the comprehensive programs such as Applied Behavior Analysis, DIR, TEACCH, and the Denver Method.The communication techniques under this heading included picture exchange systems and sign language.The Sensory techniques mentioned here include sensory integration therapy and sensory diets like the one called for in the Wilbarger Protocol.

Lets Start with Communication Techniques!The most widely used exchange system, the Picture Exchange Communication System (PECS) developed by Bondy and Frost is a structured program that teaches the exchange of symbols for communication.PECS is a systematic behavioral program that teaches a child to initiate communicative requests by approaching a communicative partner and exchanging the symbol for the desired object.It includes protocols for expanding communication from single to multiple words and for increasing communicative function from requesting to labeling and commenting.

PECS Research/Evidence BaseBondy and Frost (1994) reported a case review of a group of preschoolers with autism who were taught using PECS.Of 19 children who used PECS for less than 1 year, only two (10%) acquired independent speech, while five used speech with PECS, and 12 children used PECS as their sole communication.Of 66 children using PECS for 2 years, 39 (59%) developed independent speech, 20 developed speech as they used PECS, and 7 used only PECS.Thus, for most preschoolers introduced to PECS, it took more than 1 year after initiating PECS to observe independent speech, and many continued to have very limited spontaneous use of language.Speech tended to develop once the children were able to use 30-100 symbols to communicate (Frost and Bondy 1994).Furthermore, the overall communication development of the children was strongly related to their overall level of intellectual functioning.

PECS Research/Evidence BaseAccording to the National Research Council (2001), the only other published study using PECS was reported by Schwartz et al., (1998) on 11 children with ASD who attended an integrated preschool.These children required an average of 11 months to exchange I want + symbol sentence strips with adults and 14 months with peers.In this study, 6 (55%) of the 11 children developed functional and complex speech, and the 5 who did not were able to use PECS effectively to communicate.The authors state, however, that their study DID NOT control for maturation or the effects of other components of their school program.Whether comparable outcomes with PECS with the development of speech would have occurred without the use of other specific interventions or in older children is not known.Therefore....evidence of the efficacy of using a picture/symbol exchange system with children with ASD is only in a case study format and not in double-blind, controlled treatment research designs needed to definitively state whether it can be termed a successful intervention for individuals with ASD.

Sign LanguageAny scientific evidence presented to this effect?

Evidence Base for Sign LanguageAccording to the National Research Council (2001), there have been numerous experimental studies of the efficacy of teaching sign language to children with autism.These studies have demonstrated that total communication (speech plus sign language) training resulted in faster and more complete receptive and expressive vocabulary acquisition than speech training alone for many children with autism.

Evidence Base for Sign LanguageIn a study cited by the National Research Council, Seal and Bonvillian (1997) analyzed sign language formation of 14 low-functioning students with autism and found that the size of the sign vocabulary and the accuracy of sign formation were highly correlated with measures of fine motor abilities and tests of apraxia.Apraxia is a neurogenic impairment of planning, executing, and sequencing of movements.These findings support the role of a motor impairment in the level of competence attained in sign language and speech acquisition for children with autism, in addition to their social-communication and symbolic deficits.THUSLY.. It is very rare to find a child with autism who learns to sign fluently (in sentences) and flexibly. Signing is not generally an entry point into a complex, flexible system. (National Research Council, 2001).

A Final Word on Augmentative and Alternative Communication (AAC)This includes sign language, PECS, and FC...The National Research Council Recommends....The effectiveness of communication and language intervention programs needs to be documented relative to these core deficits and relative to the target goal of communicative competence in natural language learning environments with an emphasis on acquisition of functional skills that support successful communicative interactions.The efficacy of communication intervention should be determined by meaningful outcome measures in social communicative parameters, not just on the acquisition of verbal behaviors.Intervention research is needed that helps predict which specific intervention programs or approaches work best with which children.Intervention research is not yet available to predict which specific intervention approaches or strategies work best with which children.No one approach is equally effective for all children, and not all children in outcome studies have benefited to the same degree.National Research Council, 2001

Sensory Integration TherapiesAny evidence to support these therapies?

Sensory Integration TherapiesSensory integration therapy emphasizes the neurological processing of sensory information as a foundation for learning of higher-level skills (Ayers, 1972).The goal is to improve subcortical (sensory integrative) somatosensory and vestibular functions by providing controlled sensory experiences to produce adaptive motor responses (National Research Council, 2001).The hypothesis is that with these experiences, the nervous system better modulates, organizes, and integrates information from the environment, which in turn provides a foundation for further adaptive responses and higher order learning.

Sensory Integration Therapies EvidenceThe National Research Council cites several studies that have shown benefits of these sensory therapies on individual children.One study demonstrated that some children with ASD who were studied showed significant improvements in play and demonstrated less non-engaged play.In this same study, only one child had significant improvements with adult interactions, however non have improved peer interactions.

Sensory DietOther approaches based on sensory integration therapy include sensory diet in which the environment is filled with sensory-based activities to satisfy a childs sensory needs.No empirical studies of these approaches were identified for children with autism or related populations (National Research Council, 2001).

Sensory Stimulation TechniquesThese vary, but the underlying purpose of these is to provide passive sensory stimulation.The basis for these techniques is that a given sensory experience may facilitate or inhibit the nervous system and create behavioral changes.Examples of this approach include deep pressure (proprioceptive input) to provide calming input by massage or joint compression or through the use of weighted vests.Vestibular (movement) stimulation is another example that is sometimes used to modulate arousal, facilitate muscle tone, or to increase vocalizations. These interventions have also not yet been supported by empirical studies (National Research Council, 2001).

Evidence and Recommendations on Sensory and Motor ProgrammingUnusual sensory responses such as hypo- and hyperresponses, preoccupations with sensory features of objects, and paradoxical responses to sensory stimuli are common concerns in children with autism spectrum disorders (National Research Council, 2001).Given that most educational environments involve many sensory demands such as noise levels and unpredictable stimuli like fire alarms, interventions may need to address the individualized sensory processing needs of children who have such difficulties.However, exactly how this should be done has not been addressed in scientific investigations.There is no consistent evidence that sensory-based treatments have specific effects, in many cases, the theories underlying such approaches have not withstood careful consideration (Dawson and Watling, 2000).

Evidence and Recommendations on Sensory and Motor ProgrammingA lack of empirical data does not necessarily mean that a treatment is ineffective, but only that efficacy has not been objectively demonstrated (National Research Council, 2001).There were some nonspecific positive findings in the studies of interventions reviewed, and there is a need to address at least functional aspects of motor difficulties, particularly as they affect social, adaptive, and academic functioning.According to the National Research Council, future research in these areas need to include well controlled, systematic studies of effectiveness. Only such research can answer not only what is effective, but with whom and under what conditions (2001).

Comprehensive Treatment ProgramsIncludes Lovaas Applied Behavioral Analysis, DIR, The Denver Method, and TEACCH model.What were findings on these programs?Were they found successful?Is there evidence to support them as scientifically based treatments for ASD?

Introduction to Comprehensive ProgramsAccording to the National Research Council, various comprehensive treatment programs encompass a number of different philosophical and theoretical positions, ranging from strict operant discrimination learning (Lovaas) to broader applied behavior analysis programs, and those that highlight incidental learning, to more developmentally oriented programs (DENVER, DIR). TEACHH is eclectic with elements of both developmental and behavioral orientations (2001).

Comprehensive Program ElementsThese are common to all the comprehensive programs mentioned in this discussion.Intervention Begins EarlyIntervention is Intensive in Hours (20-45 hours of intervention per week)Families Are Actively Involved in Their Childrens InterventionStaff Are Highly Trained and Specialized in AutismThere is Ongoing Objective Assessment of a Childs ProgressCurricula Provide Systematic, Planful TeachingHighly Supportive Physical, Temporal, and Staffing EnvironmentsFocus on Communication Goals and Other Developmental AreasCarefully Planned, Research-Based, Teaching Procedures Include Plans for Generalization and Maintenance of SkillsIndividualized Intervention Plans used to Adjust for the Wide Range of Childrens Strengths and NeedsTransitions from Preschool to School Are Planned and Supported

Comprehensive Program ElementsAll of the models individualize programming around the needs of particular children, and intervention regimens are designed to be implemented in a flexible manner.Essential differences in program design pertain to whether the curriculum is aimed at addressing some or all of a childs needs and whether the program staff provide direct service or serve as consultants to external providers.

Descriptions of Models: Denver Model at the University of Colorado Health Sciences CenterThis program originally opened in 1981 as the Playschool Model, which was a demonstration day treatment program.In 1998, the treatment unit was closed, and the intervention format was changed to the more natural contexts available in home and preschool environments with typical peers (Rogers et al., 2000).This developmentally oriented instructional approach is based on the premise that play is a primary vehicle for learning social, emotional, communicative, and cognitive skills during early childhood.The role of the adult and the purpose of play activities vary across learning objectives.

Denver ModelThe overarching curriculum goals are to increase cognitive levels, particularly in the area of symbolic functions; increase communication through gestures, signs, and words; enhance social and emotional growth through interpersonal relationships with adults and peers.It is a developmental approach in that it was originally based on Piagets (1966) experientially based theory of cognitive development.The underlying assumption was that, if intervention is directed at establishing strong, affectionate, interpersonal relationships, then it may be possible to accomplish broad developmentally crucial improvements.From this perspective, it has been argued that the traditional behavioral approach of teaching specific behaviors is too narrow to have an impact on the fundamental nature of ASD (Rogers et al., 1986).

DIR: Developmental, Individual Differences, Relationship-based approach.As in the Denver model, this relationship-based approach is derived from a developmental orientation.There is a home component of intensive interactive floor-time work, in which an adult follows a childs lead in play and interaction, and children concurrently participate in individual therapies and early education programs.Intense floor time session are aimed at pulling the child into a greater degree of pleasure.

DIR (Floortime) ModelThe programs stated goal is to help the child master the healthy emotional milestones that were missed in his early development and that are critical to learning. Building these foundations helps children overcome their symptoms more effectively than simply trying to change the symptoms alone (Greenspan and Wieder, 1999).The curriculum is aimed at six developmental capacities: shared attention and regulation; engagement; affective reciprocity and communications through gestures; complex, pre-symbolic, shared social communication and problem solving; symbolic and creative use of ideas; and logical and abstract use of ideas and thing (Greenspan and Wieder, 1999).www.floortimefoundation.com

TEACCH, University of North Carolina School of Medicine at Chapel HillTreatment and Education of Autistic and related Communication handicapped CHildren.Program was founded in 1972 by Eric Schopler as a statewide autism program that serves people with ASD of all ages.Regional centers provide regular consultation and training to parents, schools, preschools, daycare centers, and other placements throughout the state.Mission: To diagnose, treat, and educate on the neurological disability, autism.

TEACCHIs based on a structured teaching approach, in which environments are organized with clear, concrete, visual information.Parents are cotherapists and taught strategies for working with their children.Programming is based on individualized assessments of a childs strengths, learning style, interests, and needs, so that the materials selected, the activities developed, the work system for the child, and the schedule for learning are tailored to this assessment information and the needs of the family.

TEACCHTEACCH has developed a communication curriculum that makes use of behavioral procedures, with adjustments that incorporate more naturalistic procedures along with alternative communication strategies for nonverbal children.National Research Council, 2001www.teacch.com

Lovaas Applied Behavioral Analysis (The UCLA Young Autism Project)Developed by Ivar Lovaas, this program was based on earlier research with older children and adolescents with autism.Its applications to young children with autism began during the 1970s.The behavioral intervention curriculum is delivered in a one-on-one discrete-trial format, which is implemented by parents and trained therapists who work in a childs home.

What is a discrete trial format?SD R SR SD = Discriminative Stimulus - The instruction given to elicit a response R = Response - The childs action in response to an SD. SR = Reinforcing Stimulus - The consequence following the childs response that changes the likelihood of that behavior re-occurring again in the future. Rewards will increase the likelihood of the behavior re-occurring, and no reward or an informational "no" will decrease the likelihood of the behavior reoccurring.

Discrete Trial FormatCan be viewed as a form of behavior modification.Behavior Modification - manipulates the stimuli (SD) and the consequence (SR) in order to change the behavior (R).

Discrete-Trial FormatHas its basis in the theory of operant conditioning.All behaviors are responses to stimuli in the environment. All behaviors are followed by consequences that affect the probability of the same behavior occurring again. If a behavior is followed by a pleasant event, that behavior is likely to reoccur. If a behavior is followed by an unpleasant event, that behavior is unlikely to reoccur.

Lovaas UCLA Young Autism Project ModelThe treatment is focused primarily on developing language and early cognitive skills and decreasing excessive rituals, tantrums, and aggressive behaviors.The first year of intervention is aimed at teaching children to respond to basic requests, to imitate, to begin to play with toys, and to interact with their families.

UCLA Young Autism Project ModelDuring the second year, the focus on teaching language continues; the most recent curriculum descriptions note a shift toward teaching emotion discriminations, pre-academic skills, and observational learning (Smith et al., 2000).

Comprehensive Program Intervention StudiesThere is a need for well-controlled clinical outcome research on these and other models of service delivery.The available research strongly suggests that a substantial subset of children with ASD are able to make marked progress during the period that they receive intensive early intervention, and nearly all children with ASD appear to show some benefit.National Research Council, 2001

Comprehensive Program Intervention StudiesHOWEVER... the research to date is not at a level of experimental sophistication that permits unequivocal statements on the efficacy of a given approach, nor do the data support claims of recovery from ASD as a function of early intervention.There is no outcome study published in a peer-reviewed journal that supports comparative statements of the superiority of one model or approach over another.Much of the current outcome information is in the form of program evaluation data or measures of childrens progress when comparisons are made before and after intervention without control groups or blinded assessments of outcome.National Research Council, 2001

Comprehensive Program Intervention StudiesOutcome data related to these models is generally based on small samples, and the small sample size has also prohibited analysis of the role of individual differences within children in the effectiveness of different models (National Research Council, 2001).The components of these models are empirically grounded. This cumulative body of procedural research serves as evidence that early educational interventions do enable young children with ASD to acquire a variety of skills (National Research Council, 2001).However, the quality and quantity of the research that evaluates the overall efficacy of these models has lagged behind the procedural research (National Research Council, 2001).SO...as of to date, we cannot say that ANY of these models is a scientifically effective treatment for autism.

Guidelines used by the Autism Society of AmericaThese guidelines can be given to parents who express a wish to know about different treatments.Will the treatment result in harm to my child?How will failure of the treatment affect my child and family?Has the treatment been validated scientifically?Are there assessment procedures specified?How will the treatment be integrated into my childs current program?Do not become so infatuated with a given treatment that functional curriculum, vocational life, and social skills are ignored.

ResourcesAmerican Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.Autism Society of America (2008, January 23). Retrieved March 18, 2008 from http://www.autism-society.org.Ayers, J. (1972). Improving academic scores through sensory integration. Journal of Learning Disabilities, 5, 338-343.Bondy, A.S., & Frost, L.A. (1994). The picture exchange communication system. Focus on Autistic Behavior,9, 1-19. Byrnes, M. (2005). Taking sides: Clashing views on controversial issues in special education (2nd ed.) Dubuque, IA: McGraw-Hill.Crook, W. (2001). Yeasts and how they make you sick (Rev. ed.) Jackson, Tenn: Professional Books.Dawson, G., & Watling, R. (2000). Interventions to facilitate auditory, visual, and motor integration in autism: A review of the evidence. Journal of Autism and Developmental Disorders 30(5), 415-421.Gerlach, E.K. (2003). Autism Treatment Guide (3rd ed.). Arlington, TX: Future Horizons, Inc.Greenspan, S.I., & Wieder, S. (1999). A functional developmental approach to autism spectrum disorders. The Association for Persons with Severe Handicaps, 24(3), 147-161.Levy, S.E., & Hyman, S.L. (2002). Alternative/complementary approaches to treatment of children with autism specturm disorders. Infants and Young Children, 14(3), 33-42.

ResourcesNational Institute of Mental Health (2007). Autism spectrum disorders complete publication. [electronic version]. Retrieved March 13, 2008, http://www.nimh.nih.gov/health/publications/autism/complete-publication.shtml.National Research Council (2001). Educating children with autism. Committee on educational interventions for children with autism. Catherine Lord & James P. McGee, eds. Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.Pangborn, J.B., & Baker, S. (2002). Biomedical assessment options for children with autism and related problems: A consensus report of the Defeat Autism Now! (DAN!) scientific effort. San Diego, CA: The Autism Research Institute.Rogers, S.J., Herbison, J.M., Lewis, H.C., Pantone, J., & Reis, J. (1986). An approach for enhancing the symbolic, communicative, and interpersonal functioning of young children with autism or severe emotional handicaps. Journal of Division for Early Childhood, 11, 135-148.Smith, T., Groen, A.D., & Wynn, J.W. (2000). A randomized trial of intensive early intervention for children with pervasive developmental disorder. American Journal on Mental Retardation, 5(4), 269-285.Umbarger, G.T., III. (2007). State of the evidence regarding complimentary and alternative medical treatments for autism spectrum disorders. Education and Training in Developmental Disabilities, 42(4), 437-447.

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