INTENSIVE BEHAVIOURAL INTERVENTION WITH AUTISM
A CASE STUDY
These notes are a summary of a case study where a Lovaas programme was implemented with a child of 6½ years.
The outcomes suggested that this approach can achieve positive outcomes despite (a) a level of intervention below that deemed apparently necessary according to initial studies, and (b) initiation of the programme at a child age well above the pre-school level recommended for maximal benefits.
M..J. Connor August 1998
Intensive Behavioural intervention with Autism: A Case Study
Albeit a single case study, the report into the effects of a year of treatment using intensive behavioural methods (according to the Lovaas programme) by Lynch 1998 is interesting for at least two reasons.
a) The subject was 6 1/2 years old at the time of the beginning of the intervention, and thus considerably older than the subjects described in the existing evaluations of this kind of treatment (including those in the original study by Lovaas in 1987).
b) There is access to clear data about actual progress in target areas of language development and reduction of self-stimulatory behaviour, rather than anecdotal or qualitative data.
The author acknowledges that the use of behavioural methods to help children with autism is well established, but notes that what is different about the Lovaas approach is the intensity of the treatment.
Forty hours per week appeared to be a requirement. although the study by Birnbrauer and Leach (1993) produced evidence for positive benefits among pre-school children of 20 hours per week of intervention.
Another issue has been the use of "aversives" as part of the programme in that part of success of the behavioural programme may have been attributed to the use of verbal or physical aversives in the initial Lovaas intervention, while subsequent studies have avoided their use. This present study emphasises the use of positive reinforcement to teach skills, in common with the trend over the recent past.
[For a full account of the original Lovaas work, and of the various critiques that have been produced, please see the earlier papers in this series, notably Connor 1998.]
What appears to be the critical issue in the Lovaas approach is the intensity of intervention by which to capitalise fully upon the way that children can learn much social behaviour by imitating other people (see Bandura 1969), and that imitation can be elicited and maintained (and generalised to other behaviours modelled) if reinforcement is provided for imitating target behaviours in the model. [See Baer and Sherman 1964.]
This particular study is also of interest because the child in question had previously been treated, over a period of 2 years, by means of the Option Approach. One can, therefore, make a largely direct comparison of the relative efficacy of these approaches (even if it was observed by Jordan (1990) that behavioural techniques do play some part in the Option Method). [For a description of the Option Approach. please see the relevant paper in this series..... January 1992.]
Current Case ("Louise")
Lynch (opp, cit.) reiterates that intensive intervention using the Lovaas programme is usually carried out with children of pre-school age, although there is some evidence for the effectiveness of the method with older children For example, McEachin and Leaf (1995) have adapted the programme to produce a form of intervention that combines a school element and a home element. Nevertheless, evidence concerning effectiveness of the approach with older children is limited.
Here, a home based programme is examined involving Louise who was 6 years 6 months old when the programme was started, and who was 7 years 6 months old with the evaluation was written. Expectations upon the effectiveness of the intervention were modified in line with the Lovaas view that children undergoing treatment should be under 4 years of age.
Louise was described as presenting as a happy baby who enjoyed physical contact but who became increasingly withdrawn from about 18 months of age. Interaction was avoided, and play became repetitive and obsessional. A diagnosis of Autism was agreed by two paediatricians when Louise was 2 years 1 month. Little progress was observed during playgroup attendance begun when Louise was 3 and extending for 6 months.
For the next 2 years, the parents treated Louise by the Option Methods a result of which she was reported to become more socially responsive and to show fewer self-stimulation behaviours, but showed no meaningful progress in verbal communication, cognitive or self help skills.
At age 4, Louise was put on a gluten and casein-free diet. No changes were observed.
Intensive behaviour therapy was begun in March 1995 at age 6:6, with a baseline assessment on the Vineland Adaptive Behaviour Scale (administered by the visiting consultant) showing the following "scores":
Communication - 1 year old level
Daily Living Skills - 1 year, 10 months
Socialisation - 7 months
Although one might have sought oppotitnities for peer interaction and minimising of social isolation, it was found that attempts to integrate Louise within a (nursery) school were not successful, and a school placement was considered inappropriate.
Intensive therapy was initiated following a weekend workshop by the consultant psychologist who provided advice on adapting the methodology to suit an older child and who provided 6-monthly supervision sessions.
Non-aversive behavioural treatment was given in 1:1 sessions of 2-3 hours each, with a weekly total of up to 30 hours. The treatment was delivered by Louise's mother and other therapists trained through workshops and regular meetings designed to ensure consistency of approach.
The emphasis was initially on imitative skills to improve attention; and upon verbal skills. Each "drill" (taking 2 to 5 minutes, and interspersed with play periods of up to 2 minutes) involved 4 steps:
a) Instruction given
b) Instruction repeated if no response
c) If necessary. instruction given a third time along with a physical prompt or verbal prompt (depending on the task)
d) Instruction given a fourth time; and the sequence if repeated if an unprompted response is not given.
The process continues until the child gives the desired response without a prompt, for which she is rewarded (with food, a toy, or social reward).
Correct responses are either ignored or treated with a "No".
Targets included spoken sounds (words, object identification, verbal naming, and "other" aspects such as (pre) reading, writing, carrying out commands, and self help skills.
In sum, re-assessments have demonstrated positive progress in all the areas targeted.
For example, the number of sounds/words in Louise's repertoire rose from virtually nil in March '95 to 100+ by March '96. It was found that generalisation of verbal skills could be taught and that Louise could produce words and labels for familiar objects in settings other than the 1:1 therapy sessions.
Repertoire of verbal naming increased from nil to around 80 during the year.
Attention and concentration spans have increased from a few seconds to around 5-10 minutes during the year ending December '96.
The author summarises the study by noting that it has to be acknowledged that, without controls, one cannot conclusively attribute progress to the behavioural intervention, but the progress since the initiation of the programme is striking (especially when compared to that achieved during the previous approach).
It is also noted that, despite anxiety about "mechanistic" responses, Louise responds well to praise as much as to tangible rewards, and that certain tasks have become intrinsically rewarding.
Further, self stimulation has decreased, compliance is greater, and there are developing skills in verbal understanding, motor skills, and self help.
It is surmised that, if the behaviour and thinking of an autistic child are inflexible or "one track", then one might anticipate a positive response to a very structured approach.
The next step will be that of introducing Louise to a classroom setting. using Lovaas methods to develop adaptive skills, with the aim of fostering further development by use of the TEACCH methodology once Louise is settled into the specialist school environment.
What matters is the demonstration of positive outcomes despite intervention falling short of the 40 hours per week (which might have been considered earlier to be a pre-requisite for success). Further, a critical element appears to be chat of task analysis to ensure that what the child is asked to do is well manageable, and linked to intrinsic and extrinsic reinforcement.
One would conclude that the intensive approach can be effective for older children; and there is further support for the notion of access to a range of methodologies to be able to match child characteristics with outcomes and to become more efficient at identifying the most appropriate (permutation of) methods for any given child.
M.J. Connor August 1998
Baer D and Sherman J. (1964). Reinforcement control of generalised imitation in young children. Journal of Experimental Child Psychology 1 37-49.
Bandura A (1969). Principles of Behaviour Modification. New York Holt.
Bimbrauer J and Leach D (1993). The Murdoch Early Intervention Program After Two Years. Behaviour Change 10(2) 63-74.
Connor M (1998). A Review of Behavioural Early Intervention Programmes for Children with Autism. Educational Psychology in Practice 14(2)109-117.
Connor M (1992). Autism: The Option Approach to Treatment. Unpublished Review. Surrey County Council EPS Kingston Upon Thames.
Jordan R (1990). The Option Approach to Autism Project Report. London National Autistic Society.
Lovaas O (1987). Behaviour Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children. Journal of Consultancy and Clinical Psychology 55 3-9.
Lynch S (1998). Intensive Behavioural Intervention with a 7-year old Girl with Autism. Autism 2(2) 181-197.
McEachin J and Leaf R (1995). Adopting the Intensive Behavioural Model to Older Children and Adolescents. Paper given to the Autism Society of America. Greenuboro 12-15 July.
© Mike Connor 1998.
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