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View from the Spectrum – The Sea of Interventions

Which approach should I use for my child? Will a behaviorally oriented method such as Applied Behavioral Analysis (ABA) work? Might it be better to use Daily Life Therapy (DLT)? What about some of the developmental ways of working with children on the autism spectrum such as the cognitive systems-based Miller Method (MM) or the affective route that Developmental Individual-difference Relation-based intervention (DIR) Floortime takes? Maybe the Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) approach is more suitable?

These are common questions people ask me at conferences and through emails on which approach to use. Looking for an answer to this question of what approach or approaches to use is part of what inspired me to write my doctoral dissertation on comparing some of the more promising approaches for treating children with autism. All too often I would find persons espousing a particular method to the exclusion of others, and ultimately, to the detriment of children on the autism spectrum.

My literature review revealed a lack of research on comparative approaches. Part of the reason may be political. Another part may relate to the difficulties in finding matched groups to compare different interventions on. While age, and to some extent cognitive functioning, can be matched, the futility of finding children matched for home lives, previous intervention experience, therapist efficacy, medical issues and other areas soon became apparent. Additionally, there are ethical issues in withholding badly needed interventions for the control group.

Rationale for the Study

As of 2008, there have been no studies on comparative approaches for working with children on the autism spectrum. One reason may center on controlling variables and the other is ethical in nature. An evidenced-based study with matched groups for each of the five methods I studied is warranted. However, difficulties in controlling variables such as previous intervention experience of the child, home life, therapist efficacy, and medical issues quickly made apparent the challenges of obtaining valid and reliable results.

Then there is the ethical question of withholding intervention for the control group for a population where providing intensive support as soon as possible is critical for maximizing developmental potential.

Therefore, I decided to open a line of research based on matching best practice to the needs of children on the autism spectrum by gathering information on how key developers of some of the more well known, promising educational/developmental/behavioral approaches think about persons with autism. We are at a crucial moment of time where autism has been recognized as a diagnosis for only about 60-65 years combined and most of these key theorists are still alive.

Diversity of Autism

There is great diversity within the autism spectrum. So many different types of people have been collected into our concept of the autism spectrum that the diagnosis of autism itself has become almost useless. This great diversity of autism speaks to two main points. Firstly, individuals are going to have widely differing needs meaning that certain approaches will work for some but not others. Secondly, finding ways to subtype people with autism may help in the endeavor of matching best practice to the needs of children with autism.

One Theorist’s Response to the Diversity of Autism

In fact, some of the key developers from the more well known, promising approaches are already doing so. For example, Arnold Miller has divided children with autism into two predominant types. The first, termed “Closed System Disorder” (Miller, A., 2007) refers to a child overly involved in the need for order in his systems. This is the child who may tantrum when an activity or routine is disrupted without a proper transition. This child may also insist that doors be closed. He or she may get so focused on an activity that the world is shut out.

In contrast, a child with “System Forming Disorder” (Miller, A., 2007) may seem to have a big dose of ADHD where they seem to orient to salient stimuli in the environment but fail to engage. A child of this nature presents as having a very short attention span.

These two types of children express autism very differently and require different interventions. Similarly, Serena Wieder and Stanley Greenspan have parsed children with autism into four subtypes.

Five Promising Approaches

ABA, TEACCH, Daily Life Therapy, DIR, the Miller Method, and RDI – When implemented by competent professionals well versed in both the method and the characteristics of the child they are working with, all of these approaches can offer great benefit. The challenge is to match the method to the child’s needs as close as possible. This decision has to be made by the parents and/or other significant caretaker along with others who are familiar with both the child’s needs and the methods available.

Given that autism initially was thought to be behavioral in nature (Rutter, 1999), the behavioral method is the oldest of approaches. The ease of measuring and assessing physical behavior also contributes to the popularity of this method. Although commonly thought of as a method even though it is not, the Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) places its main thrust on preparing the person with autism to function in the typical community and work environment (Trehin, 1999).

A third approach, Daily Life Therapy, as developed by Dr. Kiyo Kitahara (1984), of Tokyo, takes a more Platonic (1968) view by stressing an order of the physical, emotional and intellectual parts of the child. Further, the pharmacological approach sees autism as stemming from chemical imbalances that can be corrected via medication. An offshoot of this approach is the use of medicine to address secondary psychological issues such as excess anxiety and depression that can arise from being on the autism spectrum.

The developmental models more closely address the developmental delay aspects of the autism spectrum. Believing that those with autism get stuck at a particular developmental level, progress is encouraged by techniques to spur development on. Developmental Individual-difference Relation-based intervention (DIR), of which Floortime is a part, as developed by Stanley Greenspan, stresses building an emotional bond (Greenspan & Wieder, 1998) with the child, whereas the Miller Method, while sharing a developmental component with DIR, takes a more cognitive-systems approach with the implementation of elevated structures (Miller & Eller-Miller, 1989; 2000).

What Comes Next

This brief overview of the approaches studied lay the groundwork for further discussion of these interventions in terms of their areas of efficacy, contrasts, and similarities, as well as recommendations from the very persons who have been key in developing this approaches. Stay tuned for these and other topics of discussion in the next issue.

Stephen M. Shore, EdD is Executive Director of Autism Spectrum Disorder Consulting. He also is Assistant Professor of Education at Adelphi University, serves on the Board of Directors for the Autism Society of America, and serves on the Board of Directors for the Asperger’s Association of New England.

To learn more, please visit his website at www.autismasperger.net.

References

Greenspan, S. & Wieder, S. (1998). The child with special needs: Encouraging intellectual and emotional growth. Reading, MA: Addison Wesley.

Kitahara, K. (1983). A method of educating autistic children: Daily life therapy: Record of actual education at Musashino Higashi Gakuen School, Japan. Brookline, MA: Nimrod Press

Miller, A. & Eller-Miller, E. (1989). From ritual to repertoire: A cognitive-developmental systems approach with behavior-disordered children. New York: Wiley-Interscience.

Miller, A. and Eller-Miller, E. (November, 2000). “The Miller Method: A Cognitive-Developmental Systems Approach for Children with Body Organization, Social and Communication Issues”. Chapter 19. (pp 489-516) in (Eds.) Greenspan, S & Weider, S. ICDL Clinical Practices Guidelines: Revising the standards of practice for infants, toddlers and children with developmental challenges.

Miller, A. (2007). The Miller Method: Developing capacities in children on the autism spectrum. London: Jessica Kingsley Publishers.

Plato. (1968). The republic of Plato, (2nd ed). Translated by Allan Bloom. Reading, MA: Basic Books.

Rutter M. (1999). “The Emanuel Miller Memorial Lecture 1998. Autism: Two-way interplay between research and clinical work.” Journal of Child Psychology and Psychiatry and Allied Disciplines, 40, 169-188.

Trehin, P. (1999) Some Basic Information about TEACCH. Available: http://web.syr.edu/~jmwobus/autism/papers/TEACCHN.htm#Section_0.1.

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