Topic 9 - Treatment For Autism 2010

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Autism, Asperger’s & ADHD (6PS048)

ADHD, Autism & Asperger’s (6PS052)

Simon Bignell

Psychology, School of Science

Treatment For Autism

Simon Bignell – Module Leader

Lecture 9

Spring 2010 (6PS048 & 6PS052)

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Introduction To The Lecture.• Autistic Disorder.• Treatment for Autism Spectrum

Disorder.– Medication.– Behavioural Interventions.– Other Treatments.

• Problems of treatment.• Parent advocacy groups.• Prognosis.

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Objectives Of This Lecture.On completion of the lecture and with independent

study you should be able to:

1. To know the common methods of treating Autistic Disorder and Asperger’s Disorder.

2. Understand some of the issues surrounding interventions for Autism Spectrum Disorder.

3. Formulate an informed opinion on the various methods of treatment.

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• Autistic disorder is characterised by profound indifference to social relationships, odd, stereotypical behaviours, and severely impaired or nonexistent communication skills.

• The disorder typically has a chronic, unremitting course.

• No medical tests for diagnosing autism.• Accurate diagnosis is based on observation of the

individual's communication, behaviour, and developmental levels.

Autistic Disorder.

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Autistic Disorder.

Restricted, repetitive and stereotyped patterns of behaviour.

Impairment in social interaction.

Impairment in verbal and non verbal communication.

Wing, L., & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. Journal of Autism and Developmental Disorders, 9, 11-29.

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• Overlap/comorbidity (see Gillberg & Billstedt 2000).

• High overlap with ADHD symptoms.• Depression.• Mania/bipolar disorder.• Tic disorders.• “Personality disorders.”• Selective mutism.• Eating disorders.• Substance use disorders.

Comorbidity in Autism.

AUTISTICSPECTRUM

CONDITIONSATTENTION

DEFICIT/HYPER-

ACTIVITY

SEIZURES/TOURETTE’S

DEPRESSION/BIPOLAR

DISORDER

LEARNINGDISABILITIES

OBSESSIVE-COMPULSIVE

DISORDER

OPPOSITIONALDEFIANCEDISORDER

ANXIETY

Comorbidity of ASD.

And much more…

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Treatment for Autism Spectrum Disorder.

• The common view is that Autism is a lifelong disorder.

• No curative treatment.

• Symptomatic approaches.

• Two developmental periods are especially important to the course of autism: the early preschool years and early adolescence.

• Treatment depends on individual needs. In most cases, a combination of treatment methods is more effective.

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• There is no ‘cure’ for autism (yet); however, with appropriate treatment and education, many children with the disorder can learn and develop.

• Early intervention often can reduce challenges associated with the disorder, lessen disruptive behaviour, and provide some degree of independence.

• The most unpleasant traits seen in autistics are generally not the core autistic symptoms themselves.

Treatment for Autism Spectrum Disorder.

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• A huge variety of medications have been used to treat autism, including antipsychotics, antidepressants, amphetamines, psychedelics, and megavitamins.

• Unfortunately, none of these medications is an effective treatment for Autism, and few show much promise.

Medication for Autism

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Although currently no medication has been approved to treat autism spectrum disorders, survey data show that community practitioners are prescribing a broad range of medication treatments, including, but not limited to, antidepressants, stimulants, antipsychotics, alpha agonists, and anticonvulsants. Patients with autism spectrum disorders are also taking alternative treatments, including herbal remedies, immunologic treatments, and vitamin therapies, which may themselves produce side effects and/or create drug interactions with traditional medications. Although short-term data on the efficacy and safety of commonly prescribed treatments for autism spectrum disorders are increasing, few data are currently available on long-term treatment for autism spectrum disorders, but available studies and clinical experience can offer preliminary recommendations on the safety of and monitoring needs for the medications currently used for these disorders. Monitoring the safety and tolerability of drugs used in patients with these disorders should minimize the burden of side effects and optimize treatment outcome.

Medication for AutismMcCracken, J.T. (2005). Safety issues with drug therapies for autism spectrum disorders. Journal of Clinical Psychiatry. 66(10), pp.32-7.

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Medication for AutismMcCracken, J.T. (2005). Safety issues with drug therapies for autism spectrum disorders. Journal of Clinical Psychiatry. 66(10), pp.32-7.

• Community practitioners (Doctors) are prescribing a broad range of medication treatments.

• Patients with autism spectrum disorders are also taking alternative treatments.

• Few data are currently available on long-term treatment for autism spectrum disorders

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This study examined the treatment rates and patterns in children and adolescents with autism spectrum disorders (ASDs). Data were collected on 353 nonreferred children and adolescents (mean age 9.5 +/- 3.9 years; range 3-21 years) with ASDs from public schools across Ohio. Parents provided information on the use of psychotropic medicines, vitamins, supplements, and modified diets. They also completed measures of social competence, problem behavior, and adaptive behavior. Results indicated that 46.7% of subjects had taken at least one psychotropic medication in the past year. In addition, 17.3% of subjects had taken some type of specially formulated vitamin or supplement, 15.5% were on a modified diet, 11.9% had some combination of psychotropic medication and an alternative treatment, and 4.8% had taken an anticonvulsant. Logistic regressions indicated that greater age, lower adaptive skills and social competence, and higher levels of problem behavior were associated with greater medication use. This was the first study to focus exclusively on a younger population, to survey patterns of modified diets, and to obtain standardized ratings of social competence, problem behaviors, and adaptive behavior in relation to medication use. The results of this study highlight the need for more research on psychotropic medication in children and adolescents with ASDs..

Witwer, A. & Lecavalier, L. (2005). Treatment incidence and patterns in children and adolescents with autism spectrum disorders. Journal of Child Adolescence and Psychopharmacology. 15(4), pp. 671-81.

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• Treatment rates in children and adolescents with autism spectrum disorders.

• Parents provided information on the use of psychotropic medicines, vitamins, supplements, and modified diets, social competence, problem behaviour and adaptive behaviour.

• 46% taken psychotropic medication; 17% had taken food supplements/vitamins; 15% were on a modified diet, 12% had some combination of psychotropic medication and an alternative treatment.

Witwer, A. & Lecavalier, L. (2005). Treatment incidence and patterns in children and adolescents with autism spectrum disorders. Journal of Child Adolescence and Psychopharmacology. 15(4), pp. 671-81.

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Behaviour Modification Treatment.

Many different types of behavioural based interventions for ASD. but general agreement that:

• Usually beneficial, sometimes very beneficial.• Most beneficial with young children, but older

children can benefit.• Despite the fact that Autism apparently is caused

by neurological abnormalities, the most effective treatment for the disorder is highly structured and intensive ‘Applied Behavioural Analysis’ (ABA). (See: Lovaas, 1987; McEachin et al., 1993; Smith et al., 2000.).

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Applied Behaviour Analysis (ABA).

• APPLIED - strives to produce rapid and clear benefit to problems of social importance.

• BEHAVIOURAL - uses objective and accurate measurement of the behaviour of interest.

• ANALYSIS - uses controlled (single-case) methods to understand the environmental variable(s) that influence an individual’s behaviour.

(Baer, Wolf, & Risley, 1968).

“…studies have shown that one treatment approach - early intensive treatment using the methods of Applied Behavior Analysis - can result in dramatic improvements for children with autism…”

(Maurice, Green, and Luce, 1996).


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Outcomes of ABA for Autism

0

5

10

15

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25

30

35

0 5 10 15 20 25 30 35 40 45

Hours per Week of Treatment

Incr

ease

s in

IQ

Sco

res

r = .79p < .02

About 50% of Children with Autism and mild mental retardation who received early intervention with ABA attain normal IQs and are educated in regular classrooms with minimal assistance.

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• Why is ABA Effective?

• ABA developed from and remains closely linked to basic research on the principles of learning and behaviour.

• A central principle of ABA is called “Selection by Consequences.” (operant conditioning techniques)

• In a given environment, behaviours that produce favourable outcomes are selected (or continue to occur) and those that produce unfavourable consequences are extinguished.


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• ABA has developed a wide variety of procedures for identifying the antecedents and consequences that influence behaviour.

• The antecedents and consequences in the environment are rearranged so that appropriate behaviour is selected (or re-occurs) and problem behaviour is extinguished.

• Specific procedures include:

• Shaping.• Chaining.• Prompting.• Fading.• Extinction.• Reinforcement.• Generalisation strategies, etc.


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Why is ABA Effective with Autism?

• Comprehensive: Teaches all skills (e.g., sitting, attending, imitating, direction following, language, social skills, self-help skills).

• Goal and Data Driven: The focus on objective measurement and analysis of behaviour provides ongoing feedback on progress and setbacks.

• Empirical Emphasis: Treatments are based on principles and procedures supported by research.

• Intensity Level: 25 to 40 hours per week for 3 years.


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Example of individual goals for a child with ASD:• Decease self-injurious behaviour.• Increase eye contact.• Increase spontaneous requesting.• Increase labelling skills.• Increase use of yes and no.• Increase imitation skills.• Increase matching skills.• Increase letter identification.• Increase self-feeding skills.


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For example…Teaching Imitation Using Discrete Trials:

• Starts with simple responses (e.g., clapping).

• Sessions consisting of 10 trials; each trial starts with the therapist saying “Do this” and then modelling the target response.

• Any approximation of clapping, results in delivery of a preferred reinforcer (e.g., toy).

• Otherwise, the therapist guides the child’s hands to complete the response and then begins the next trial…


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Teaching Imitation Using Discrete Trials (continued).

• Once the first response is mastered, the same procedure would be used to teach a second response (e.g., waving).

• After two responses are mastered in individual sessions, they would alternately be presented in the same session (e.g., “Do this” [clapping]; “Do this” [waving]).

• Over time, additional responses are added until the child immediately imitates any new action the therapist does following the prompt, “Do this.”


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Generalisation of Skills.

• Skills taught during discrete trials are then generalised to natural settings.

• e.g., Clapping when another child answers correctly during group instruction or at a recital or school assembly.

• e.g., Waving to another person when entering or leaving a room.


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Early Behavioural Intervention for Autism.

• Year 1 - reduce aberrant behaviour, teach attending, imitation, instruction following, speaking in short phrases, play skills, and self-help skills.

• Year 2 - extend expressive vocabulary, more abstract concepts, extend treatment to group and community settings.

• Year 3 - pre-academic and academic skills, appropriate emotional expression, observational learning, and interactions and friendships with normally developing peers.

• A 3 year early intervention represents a cost-effective (£££) intervention only if viewed over the lifespan.


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Other Treatments for AutismDietary modifications for Autism:

The Gluten-free/Casein-free Diet (GfCf).

• GfCf diet found to be helpful in eliminating many ASD behaviours and digestive problems.

• Requires elimination of wheat, dairy, soy, and often many other foods.

• Often requires lifestyle change for whole family.

• Foods expensive, hard to find in some areas.

• Much of what the diet does can also be accomplished using appropriate enzymes.

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Other Treatments for AutismCommunication therapy.

Visual structure in the bathroom: How to brush my teeth

Visual structure in the classroom: No kicking other children !!!

Various techniques used in school and at home as part Special educational needs provision.

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Other Treatments for AutismFor example:• Metal Detoxification (chelation); Anti-fungal; Gastro treatments;

Metabolic Disorders; Secretin (topical & IV); Nutritional Therapies (Supplements) & Diet(s); Oral, topical, nasal/nebulised and Push/IV (for example: B-12, Vitamin C, Glutathione); Hyperbaric Oxygen Treatments (HBOT); IV & Oral Immunoglobin therapies; Bio and Neurofeedback; Craniosacral & Chiropractic Therapies.

• See also: T.E.A.C.C.H.; Sensory Integration (SI); Speech Therapy; Occupational Therapy (OT); Physical Therapy; Auditory Integration Therapy (AIT); Vision training and Irlen lenses; Relationship Development Intervention (RDI).

• It is important to note that most of the theories of environmental factors have little or no scientific evidence behind them.

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Problems of Treating Autism.

• Communication impairments.• Non-compliance.• Consent.• Intellectual/emotional Immaturity.• Vulnerability.• Comorbid problems (e.g. gut problems).

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Parent Advocacy Groups

• These groups often offer information, hope and support to parents.

• See National Autistic Society (UK) for a balanced view.

• See also ‘Defeat Autism Now!’ (DAN); ‘Cure Autism Now!’ (CAN) in US for more radical views.

• However, they can also promote pseudo-science, quackery and untested claims of treatments. (See chelation ‘therapy’).

• Autism is a multi-million £ market for the pharmacological industry, publishers and those who seek to provide expensive interventions and ‘cures’.

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Combating Autism Act 2006 (USA)

• Authorises nearly $1 billion over the next five years to combat Autism through research, screening, early detection and early intervention.

• Will increase US spending on Autism by at least 50 percent.

• Includes provisions relating to the diagnosis and treatment of persons with Autism Spectrum Disorders, and expands and intensifies biomedical research on Autism, including an essential focus on possible environmental causes.

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Prognosis

• The academic/scientific consensus is that there is no cure for Autism.

• However, with appropriate treatment and education, many children with the disorder can learn and develop.

• Early intervention often can reduce challenges associated with the disorder, lessen disruptive behaviour, and provide some degree of independence.

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Summary - Key Points• Children with Autism can achieve large,

comprehensive and lasting gains with appropriate interventions. (See: Birnbrauer & Leach, 1993; Charman, 2003; Couper, 2004; Fenske et al., 1985; Scheinkopf & Siegel, 1998; Smith, Groen et al., 2000; Spiker, Hebbeler, & Mallik, 2005.).

• Behavioural interventions are the most effective.• Treatment depends on the individual. In most cases, a

combination of treatment methods is more effective. • Autism usually requires lifelong intervention/treatment.• Scientists are searching for methods of treatment but

what aspect of Autism could be ‘cured’?

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Simon Bignell


Any Questions?

Topic 9 - Treatment For Autism 2010

Education