Should Your Child with ASD Attend School this Fall?
As parents of children with autism are planning for next Fall and the start of a new school year, they are wondering whether to enroll their child in a regular school program. Nearly all parents want their children with autism to attend school alongside their typical peers. They believe that will promote social skills and help in developing friends. Sometimes it works well, but
often not, depending on how much additional Early Intensive Behavioral Intervention the child receives and his/her functioning level.
Two recent studies, one in Norway and the other in the US, suggest that three hours per day of intensive Early Behavioral Intervention combined with several hours per day of participation in school led to significant improvements among the children with autism, but participating in regular school alone did not. In one study, parents also agreed to give the toddlers with autism ten hours each week of additional interventions at home that helped their progress.
A recent regrettably negative study published by McPheeters, Warren, et.al. in Pediatrics suggests there is little evidence any treatments are effective for autism except risperidone and aripiprazole. The review’s conclusions are contrary to nearly all of the other reviews of similar research over the past 6-7 years that show unequivocally that Early Intensive Early Behavioral Intervention is highly effective for many children with autism. "I really don't like it when I see reviews that systematically say we're not looking at single-subject studies, because that's where some of the best evidence lies," notes Laura Schreibman, professor of psychology at the University
of California, San Diego (shown here). There are within subject research designs that provide strong evidence according to the Oxford University Centre for Evidence Based Practices, which the McPheeters/Warren et. al. group unfortunately excluded from their analysis. The Institute of Medicine has published a monograph on Small Clinical Trials which would have been helpful to these authors. Regrettably many clinical researchers have forgotten the lesson of Claude Bernard, the father of modern physiology and medicine. Bernard introduced the within subject reversal experimental design (ABA) for demonstrating effects of physiological variables within individual subjects. Bernard’s goal was to understand, by which he meant to be able to predict and control, factors affecting functioning of individual people, not the average person. (Bernard, 1865; Trans, 1927). His lesson stands as true to day as it did nearly a century and a half ago (see image below).
LEAP (Learning Experiences and Alternative Program for Preschoolers and Their Parents) is one of two evidence based inclusion models for the education of young children with ASD and implemented in public school settings. Most of the other behavioral programs with demonstrations of efficacy, children begin their intervention in one-to-one intervention n the home, a clinic, or in a class with only children with ASD (Strain and Bovey, 2011). LEAP relies on incidental behavior analytic teaching strategies similar to milieu language intervention, pivotal response training and positive behavior support methods, within naturalistic school settings in which many classmates are typical peers. LEAP employs a minimum ratio of adults to children (1:5) and minimum ratio of typical peers to children with ASD (2:1), so it is not a typical regular education classroom. In a very recent study with 56 children, half receiving LEAP intervention over two years of teacher and parent training and mentoring by LEAP professional staff, and the other half only reading the LEAP manual. Children were similar on all measures at start. After 2 years, LEAP-trained class children were found to have made significantly greater improvement than their comparison cohorts on measures of cognitive, language, social, and problem behavior, and autism symptoms. The improvement in Childhood Autism Rating Scales scores (i.e. autism symptoms) were modest but significant (from 39 to 32). A CARS score of 30 is the usual cut-off for a tentative autism diagnosis. The fidelity with which teachers implemented LEAP strategies predicted outcomes (Strain and Bovey, 2011). This study suggests that moderate to higher functioning children on the autism spectrum may profit from participation in an integrated classroom structured around the LEAP model, but the gains may be less, particularly in the beginning, than one to one intervention. It also suggests that placing a child with autism in a regular education classroom without substantial support of the teacher by specialists is likely not to be helpful.
The long and short of it is that your best bet is to enroll your 2-5 year old child with autism in an Early Intensive Behavioral Intervention program for at least 15-20 hours per week, more for children with more severe disability. Emphasis should be on communication and social skills. Incorporating typical peers can be extremely helpful once the child begins making significant progress on their social skills and communication that are necessary to play with peers, participation in school can be a real plus for many children on the autism spectrum.
Bernard, Claude. An Introduction to the Study of Experimental Medicine, 1865. First English translation by Henry Copley Greene, published by Macmillan & Co., Ltd., 1927;
Eldevik S. et al. J. Autism Dev. Disord. Epub ahead of print (2011)
Institute of Medicine (2001) Small Clinical Trials: Issues and Challenges. Washington DC.
McPheeters, Warren Z. et al. Pediatrics Epub ahead of print (2011)
Stahmer A.C. et al. Autism Epub ahead of print (2011)
Strain, PS and Bovey II, EH (2001) Randomized, Controlled Trial of the LEAP Model of Early Intervention for Young Children With Autism. Topics in Early Childhood Special Education published online 25 May 2011