Clinical Intervention for Autism Spectrum Disorder: Methods of Intervention by Andjela Vulovic

Abstract

This experiment aims to study how an integrative approach to early clinical intervention for Autism Spectrum Disorder (ASD), might be more beneficial than a “single-therapy” approach. The intervention offered in the experiment will be a combination of cognitive behavioral therapy, applied behavior analysis, and occupational therapy. As past literature shows, each of these has projected positive outcomes for individuals on the Autism Spectrum. Cognitive Behavioral Therapy helps reduce anxiety and aids in social development, while Applied Behavior Analysis helps with language development and Occupational Therapy produces desired skill-based outcomes. If we combine all three of these therapies into one integrative system, we will see more overall positive outcomes than by using each therapy individually.

Keywords: Autism Spectrum Disorder, ASD, Cognitive Behavioral Therapy, Applied Behavior Analysis, Occupational Therapy, Development, clinical intervention, early clinical intervention.

Introduction

As explained by Autism Speaks, early intervention has been proven to produce the most significant positive outcomes for the development of those with Autism Spectrum Disorder (Autism Speaks, 2018). However, what is not known is what kind of early intervention can produce the most favorable outcomes. There is a variety of different therapies, such as cognitive, applied behavior analysis, and occupation.

Problem Statement

When it comes time to choose, parents are often stuck between trying to decide whether they should overload their child with many various therapies, or whether they should just stick to one. It is hard to pick only one, however, when all of the types of therapy are linked to positive outcomes in different areas of development. Having to make this choice can put an emotional and financial burden on the parents.

Hypothesis

This study proposes that if we are to link all three of the previously mentioned therapies, into one integrative approach, we will be able to see a greater overall improvement across developmental outcomes. By creating an integrative approach, we will be able to lessen the parent’s burden of having to choose which area of development to focus on. In this experiment of 50 children between the ages of 2 and 5 that have been formally diagnosed with Autism Spectrum Disorder level 1 severity, we will be able to see if an integrative approach produces a greater overall outcome when compared to individual therapies. The experiment will last for a period of 2 years, so that each participant has ample time to go through developmental milestones.

Review of Literature

When talking about Autism Spectrum Disorder, it is clear that early intervention is often the best approach. In fact, the American Academy of Pediatrics recommends routine screening for autism as young as 18 months old. When we engage in intervention for Autism, there are many different routes that can be taken, and each one shows a significant improvement in at least one area of function. For example, Cognitive Behavioral Therapy can help dissolve anxiety disorders in those with ASD and Applied Behavior Analysis shows positive effects in language development, as well as additional outcomes. Additionally, Occupational Therapy shows skills-based improvement.

Cognitive Behavior Therapy

Cognitive Behavioral Therapy (CBT) is typically used for short term goal oriented treatment (Martin, 2018). The objective of CBT is to change the patterns of one’s thinking and behavior so that they may change an individual’s emotional response. For Autism Spectrum Disorders, this type of therapy is used to help with anxiety as the two are often comorbid. In a 2009 study, 40 children between the ages of 7 and 10, diagnosed with both ASD and an anxiety disorder, were randomly assigned to either a 3-month waitlist or 16 CBT sessions (Wood, Drahota, Sze, Har, Chiu, Langer., 2009). By the end of the study, the results reported that 78.5% of the children in the experimental group met Clinical Global Impressions-Improvement scale criteria for positive treatment response, while the control group only showed 8.7% (Wood et al., 2009). This study suggests that children with high functioning autism are able to achieve remission of anxiety disorders through the use of Cognitive Behavioral Therapy.

Applied Behavioral Analysis

While Cognitive Behavioral Therapy aims to achieve short term goals, Applied Behavior Analysis (ABA) focuses on learning or improving a certain behavior. For individuals with Autism Spectrum Disorder, this can help develop communication skills, fine motor skills, and domestic capabilities. ABA therapy typically happens in 3 steps. First, there is an antecedent such as a verbal request. This is followed by a resulting behavior, which is then reinforced by a consequence (Autism Speaks, 2018). A 2010 meta-analysis of ABA intervention for Autism Spectrum Disorder found that although there were positive effects across all measured outcomes, language related outcomes showed more improvement than daily living and social functioning skills (Virues-Ortega, 2010). Applied Behavior Analysis is also the cornerstone for varying branches of treatment such as the Early Start Denver Model.

Early Start Denver Model. The Early Start Denver Model (ESDM) is an Autism intervention approach that can be used for children as young as 12 months old (Autism Speaks, 2018). It is a relationship-based approach that uses techniques consistent with Applied Behavior Analysis. In a 2010 longitudinal study of 48 children diagnosed with ASD between 18 and 30 months of age, results found that the children who received ESDM intervention showed positive improvements in adaptive behavior and IQ (Dawson, Rogers, Munson, Smith, Winter, Greenson, Donaldson, Varley.,2010). Two years later, the ESDM group showed an average improvement score of 17.6 when compared to the baseline (Dawson et al., 2018). The control group, on the other hand only showed an average improvement score of 7.0 (Dawson et al., 2018). Additionally, this study found that the ESDM children were also more likely to have their diagnosis change from Autism Spectrum Disorder to Pervasive Developmental Disorder (Dawson et al.,2018)

Occupational Therapy

Occupational Therapy aims to increase independence. For children on the Autism Spectrum, occupational therapy focuses on teaching daily tasks within the child’s functional ability. Often times, Occupational Therapists will use Sensory Integration as a part of therapy. A 2017 systematic review sought to study the efficacy of Ayres Sensory Integration in Occupational Therapy (Schaaf, Dumont,, Arbesman, May-Benson., 2017). The review found strong evidence of improvement for individualized goals and moderate evidence of improvement for skills-based outcomes. Additionally, there was emerging, but insufficient, evidence linked to independence in the form of reduced caregiver assistance (Schaaf et al., 2017).

Methodology

As the literature review expressed, there are many forms of early intervention when it comes to Autism Spectrum Disorder and they all come with their own sets of rewards. Cognitive Behavioral Therapy has been shown to help lessen the prevalence of anxiety disorders in individuals with Autism Spectrum Disorder, Applied Behavior Analysis shows positive outcomes in language development, and Occupational Therapy shows improvements in skill-based tasks. However, this study hypothesizes that if an individual with Autism Spectrum Disorder were to interactively use all three therapies, they would see more positive effects in overall development than if they were to use any of the three therapies individually.

Research Design

For this study, the research design would be experimental. An experimental design would be the best for this study because it would offer high control, which would enhance internal validity. The experiment would be conducted longitudinally, where the same individuals would be monitored over time to see how the intervention compared to the control group.

Setting

The first part of the study would be completed in a controlled setting that the participant is not intimidated by. In my opinion, the ideal setting for this would be a “play room” that is stocked with some toys that can be used as instruments for measuring the individual’s developmental stages.

Population

As this study is aiming towards discovering the effects of an integrative approach to early clinical intervention for Autism Spectrum Disorder, the population would consist of 50 children between the ages of 2-5 that have been formally diagnosed with Autism Spectrum Disorder, Level 1. The age range would be between 2 and 5 years old because the experiment aims to study early intervention. Additionally, the severity of the population would be level 1 so that we may be able to use “language development” and “caregiver independence” as areas that are projected to improve over the course of intervention.

Instruments

In order to establish a baseline, as well as to monitor projected positive outcome of the therapies, a variety of developmental milestone tests would be given to the participants. The tests that would be used are the Pediatric Evaluation of Disability Inventory (PEDI), Vineland Adaptive Behavioral Scales, and Verbal Behavioral Milestones Assessment and Placement Program (VB-MAPP). The PEDI would be used to measure performance of functional activities in mobility, daily activities, and social/cognitive abilities. The Vineland Adaptive Behavioral Scales would be used to measure 5 domains: communication, socialization, motor skills, maladaptive behaviors, and daily living. The VB-MAPP would be used to measure 16 skills: mand, tact, intraverbal, listener, echoic, imitation, textual, copying, transcription, listener responding, visual perceptual, independent play, social behavior, spontaneous vocal behavior, group skills, linguistic structure and math. All of these tests have varieties that take 20 minutes or less to complete, and all of them have been used for younger children diagnosed with Autism Spectrum Disorder.

Procedures/ Data Analysis

First, participants would be equally randomly assigned to two groups so that each group has 25 children. Group A (the control group), would receive no intervention on basis of the experiment, and would be monitored over 2 years to see how their developmental outcomes measure to the experimental groups. Group B (the experimental group) would receive once-a-week integrative therapy which would combine Cognitive Behavioral Therapy, Applied Behavior Analysis, and Occupational Therapy. The tests would be conducted before the experiment begins, 12 months into the experiment, and at 24 months, when the experiment would be completed. The scores of group A and group B would be compared to see if the integrative approach yielded more positive outcomes.

Limitations

This study would not be able to account for what therapies the control group participants partake in alongside the experimental group. Additionally, the study would not take into account any adverse childhood experiences that could potentially alter the developmental growth of each child.

Ethical Considerations

Since this study would be working with a highly sensitive population, extreme protective measures would need to be put in place so that no child experiences any harmful risks as a result of the intervention. Additionally, informed consent would be explained to the guardians, as well as all of their rights when it comes to the experiment. They would be ensured that they may leave the study at any time, and that all of their data will remain anonymous.

Conclusion

This experiment would offer some insight into the effects of integrative early clinical interventions on the development of children with Autism Spectrum Disorder. If the integrative approach yields greater overall developmental improvement than the control group, an integrative approach can be offered to parents. This would mean that parents would not have to make the hard choice of deciding if they can afford all of the therapies and if they want to put stress on their child by having them attend so many various treatments. By reducing the burden on parents, we can potentially see lower stress levels in the caregivers, which could in turn result in better overall care for children on the Autism Spectrum. This experiment would serve as a stepping stone, by being able to study if an integrative approach is better than a single-therapy approach.

References

Autism Speaks. (2018). DSM-5 Diagnostic Criteria. Autism Speaks Inc. Retrieved from https://www.autismspeaks.org/what-autism/diagnosis/dsm-5-diagnostic-criteria

Autism Speaks. (2018). Treatments and therapies. Autism Speaks Inc. Retrieved from https://www.autismspeaks.org/family-services/tool-kits/100-day-kit/treatments-therapies

Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., Varley, J. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The early start denver model. The American Academy of Pediatrics, 125(1), 17-23. Retrieved from doi:10.1542/peds.2009-0958

Haley, S.M., Coster, W.J. & Dumas, H.M. (2012). Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT version 1.3.6): Development, Standardization and Administration Manual. Boston, MA: Health and Disability Research Institute

Martin, B. (2018). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved on August 12, 2018, from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/

Schaaf, R.C., Dumont, R.L.,Arbesman, M., May-Benson, T.A. (2017). Efficacy of occupational therapy using Ayres Sensory Integration: A systematic review. American Journal of Occupational Therapy, 71(1). Retrieved from doi:10.5014/ajot.2018.028431

Sparrow, S.S., Cicchetti, D.V.& Balla, D.A. (2005). Vineland– II: Survey Forms Manual. Circle Pines, MN: American Guidance Service

Sundberg M.L. (2008). Verbal Behavioral Milestones Assessment and Placement Program. Concord, CA: Advancements in Verbal Behavior Press.

Virués-Ortega, J. (2010). Applied behavior analytic intervention for autism in early childhood: Meta-analysis, meta-regression and dose–response meta-analysis of multiple outcomes. Clinical Psychology Review, 30(4), 387-399. Retrieved from https://doi.org/10.1016/j.cpr.2010.01.008.

Wood, J.J., Drahota, A. Sze, K., Har, K., Chiu, A., Langer, D.A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial. The Journal of Child Psychology and Psychiatry, 50(3), 224-234. Retrieved from https://doi.org/10.1111/j.1469-7610.2008.01948.x