Proponents of one early intervention approach versus another often point out that the methods they are advocating grow out of a specific theory of child development orlearning. In reality, despite theoretical differences, early intervention methods often share significant features in common (e.g., following the child’s lead is common to PRT, Floortime, and Incidental Intervention) but may differ widely in other respects, not necessarily having very much to do with their preferred theory. In this article I will examine some factors that have been shown to affect child outcomes of EIBI.
The importance of intensity of a child’s early experiences is not specific to ABA therapy and autism. In a landmark study, Betty Hart and Todd Risley (1995) studied language and intellectual development of typically developing preschool children growing up in poor inner-city neighborhoods and others whose parents were middle-cla
ss professional families. Although it wasn’t surprising that the two groups of children displayed some language differences, what was surprising was the profound differences in the language experience of the two groups of children and the resulting differences in intellectual and language competence. In a review of the role of intervention intensity in language intervention, Warren, Fey, and Yoder (2007) noted, “ Cumulative intervention intensity makes a meaningful difference in language learning.” They also emphasized that it isn’t always the case that massed trials, as usually occur in DTI, yield superior results to distributed practice even when they have a similar total time in intervention. However, if a child receives 30 hours per week of EIBI, it would be difficult to achieve comparable total intervention intensity by spacing intervention episodes farther apart, unless the intervention periods included weekends and evenings. In a more recent study, Steve Warren and colleagues (Warren et al., 2009) used an automated device to track all utterances of preschool children with autism and those of people around each child, such as parents or therapists. They found that during periods when children with autism were in therapy, the number of the child’s total utterances, including conversational exchanges, greatly increased.
Several studies of ABA-based autism early intervention indicate that engaging in more hours per week of early intervention produces greater improvements in intellectual, language, and social functioning than fewer hours (Cohen, Amerine-Dickens, & Smith, 2006; Eikeseth, Smith, Jahn, & Eldevik, 2002, 2007; Lovaas, 1987). In comparison to the high intensity studies, several lower-intensity intervention programs have also been conducted, while reporting improvements, generally with lesser reductions of autism symptoms and skills improvement (Bibby, Eikeseth, Martin, Mudford, & Reeves, 2002; Remington et al., 2007; Smith, Buch, & Gamby, 2000; Smith, Groen, & Wynn, 2000).
Most evidence indicates that 25–30 hours per week of one-to-one intervention over the first 1–2 years is required to make significant gains in core autism symptoms for most children who are responsive to this form of intervention (Lord & McGee, 2001) with the exception of higher functioning children (e.g. Asperger disorder) who may profit substantially with lesser intensity of naturalistic intervention. Some parents prefer to begin with 10 to 20 hours of therapy per week and then increase intervention intensity later if the child’s gains are judged to be insufficient. It is important to bear in mind that the majority of cognitive, language, and social gains are made in the first 18 months of early intervention Increasing intervention intensity after 1 to 2 years may not compensate for learning that did not occur during the period when most rapid skill development and brain connectivity normally occur. Providing inadequate intensity during that early period undermines the purpose of EIBI.
Contextually Nested Interventions
Skills taught out of context may not generalize to natural settings where they are ultimately intended to be displayed. Using stimuli and reinforcers that are unrelated to the context (e.g., tokens instead of natural consequences for requesting a sippy cup of apple juice) is less likely to engender generalization and maintenance once therapy is phased out. Tying a child’s verbal or picture symbol requests to their natural consequences, such as a preferred activity, will make it more likely the child will make a similar req
uest under comparable circumstances in the future. Discrete trial or incidental teaching sessions embedded within normal daily routines at school or home are more likely to be adopted by caregivers and to be maintained when specialized instructional or therapy staff are not present. At times it may be necessary to conduct massed therapy or learning trials taught out of context to maintain the child’s attention and
to teach difficult discriminations. However, when it is possible to do so, capitalizing upon incidental learning opportunities within natural contexts can be highly effective.
Multiple Teachers/Therapists and Multiple Settings
No systematic studies have been reported of the role of multiple teaching or therapy staff across several settings in early intervention programs. In the National Research Council review (Lord & McGee, 2001), conducting such a study was one of the recommendations. Based on intolerance of children with autism for changes, including interacting with different people, and in order to promote generalization across settings, this is a reasonable recommendation, and one we routinely employ in our early intervention endeavors.
Participation of Siblings and Peers
Tobias, who just turned 3 years old, spends Monday, Wednesday, and Friday mornings in a typical preschool classroom. He has been diagnosed with PDD-NOS. He watches two boys playing with cars on a mat in the play area. He approaches them and hesitates. He appears to want to play with the boys, but he doesn’t know how to join in. Finally, he kicks a ball so it ricochets across the floor and bangs into the boys’ toy cars. They shout at him, “ Stop it! Go away!” Tobias runs away crying. Few preschool-age children with autism have the skills to play interactively with same-age peers, other than very simple “ chase” or “ play fight” games similar to those they see on cartoons. Often siblings learn to accommodate their sister or brother with an ASD, facilitating limited play while at home, but that seldom generalizes to interacting effectively with other children who are less motivated to find ways to be helpful to the child with autism. One approach to encouraging peer-oriented social skills involves nesting intervention within an integrated setting along side neurotypical peers.
Gail McGee’s Little Walden program, at Emory University (McGee & Morrier, 2009),
and Phil Strain’s LEAP school-based interventions (Strain, McGee, & Kohler, 2001) explicitly combine children with autism with neurotypical peers in order to promote appropriate social interactions. Although that may be effective for some higher functioning children, in our experience more explicit teaching of basic communication and social skills is necessary to enable most children with autism to initiate and sustain social interactions with peers, including games and toy play. Interventions that explicitly teach interactive play and communication with peers are more likely to have positive outcomes. By all means, typical siblings and peers can be included in carefully crafted social interaction activities with your child or student with an ASD, but don’t expect her or him to learn by osmosis to be socially competent.
Proactive Strategies for Preventing Behavioral Challenges
Effective EIBI programs do not wait for behavioral challenges to arise before acting. They anticipate and prevent them. Most behavioral challenges in young children with ASDs are a result of a child’s inability to communicate needs and wants, as well as being thwarted in highly preferred activities or access to desired commodities. Proactive strategies that obviate the need for tantrums, aggression, and other emotional/behavioral outbursts can be highly effective (Carr et al., 2002).
*[Excerpted from Ch. 4. in T. Thompson Individualized Autism Intervention for Young Children: Blending Discrete Trial and Incidental Approaches. Baltimore: Paul H. Brookes Publishing Company]
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Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W. et al. (2002). Positive Behavior Support: Evolution of applied science. Journal of Positive Behavior Interventions, 4(1), 4-16.
Cohen, H., Amerine-Dickens, M., & Smith, T. (2006). Early intensive behavioral treatment: replication of the UCLA model in a community setting. Journal of Developmental and Behavioral Pediatrics, 27(2 Suppl), S145-55.
Committee on Educational Interventions for Children with Autism, N. R. C. (2001). Educating children with autism, C. E. Lord and J. McGee, Editors) Washington, DC: National Academies Press.
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Warren, S. F., Gilkerson, J., Richards, J. A., Oller, D. K., Xu, D., Yapanel, U. et al. (2009). What Automated Vocal Analysis Reveals About the Vocal Production and Language Learning Environment of Young Children with Autism. Journal of Autism and Developmental Disorders.