Types of Early Intervention Therapies

Early Intervention (EI) therapies are the usual behavioral treatment for autism.  However!  There are a lot of types of EI – how do they all work and which one is best for your child?  Here, we describe how different types of Early Intervention (EI) are performed and what the goals of each therapy are.

 

Applied Behavior Analysis (ABA)

ABA is the most commonly used type of EI because its effectiveness is scientifically proven.  ABA’s goal is to alter a child’s problem behaviors (kicking, hitting, ignoring people, etc…) through positive reinforcement.

ABA therapy is performed one-on-one and sessions are tailored to the needs of the child.  Generally, ABA clinics will perform an evaluation of the child to identify skills to focus on before beginning treatment.  Parental participation in the therapy is strongly encouraged.  ABA works off of the idea that children engage in certain behaviors because the behavior benefits the child in some way.  ABA utilizes antecedents and consequential events to identify patterns in a child’s behaviors, then reinforces positive behaviors or replaces “maladaptive behaviors” (bad behaviors) with better alternatives [2].  Ultimately, ABA seeks to identify what a behavior “does” for the child, then teaches the child replacement strategies for achieving their desired outcomes.

  • An antecedent is an event that occurs immediately before a behavior and impacts a patient’s current behavior.  For example, a parent asking a child to stop playing a computer game and come to dinner could be an antecedent, and the child ignoring the parent could be the maladaptive behavior that follows.
  • A consequential event impacts whether that behavior will occur in the future when the antecedent is present.  So in our example, if ignoring their parent means that the child gets to keep playing their computer game, they may be more likely to ignore their parent in the future.

All 50 states have taken action to require that both public and private insurance providers cover ABA.

For more information about ABA, please see The Autism Center of Ascension Sacred Heart’s Introduction to Applied Behavioral Analysis video.

For information on the efficacy of ABA, please see Efficacy of Interventions Based on Applied Behavior Analysis for Autism Spectrum Disorder: A Meta-Analysis

 

Early Start Denver Model (ESDM)

As described by Autism Speaks, the ESDM uses ABA methods to help the patients build positive relationships. ESDM therapists use play and joint activities to help patients perform real-life activities, and develop language skills.  ESDM works by:

  • Promoting “turn-taking” behavior and imitation.  Imitation encourage children to imitate the desired behavior with positive reinforcement.
  • Addressing all developmental domains – it is designed to improve several skills at once
  • ESDM has a large time commitment which may be challenging for certain households.
  • Please see the Early Start Denver Model to see a video example of a ESDM session.

 

Picture Exchange Communication System (PECS)

PECS uses pictures to help children with little or no language communicate.  The goal is to encourage independent, un-prompted communication.  Through PECS training, children learn to make “sentences” using pictures.  PECS works by:

  • Teaching children to use pictures for speech.
  • Encouraging children to speak better or sign better when using pictures.
  • Giving students a way to engage in more social interaction.

Patient who may benefit from PECS may:

  • Not have imitation skills.
  • Have some speech, but speech may not be functional.
  • Have speech but don’t initiate.
  • Have very limited speech without expansions or descriptions
  • Have speech that is difficult to understand by unfamiliar people

PECS therapy consists of 6 phases:

  • Phase 1: Children learn to exchange single pictures for items they want.
  • Phase 2: Still using single pictures, children use this new skill in different locations.
  • Phase 3: Children learn to discriminate between two different pictures.
  • Phase 4: Children learn to form simple sentences using an “I want” picture prompt.  “I want” is followed by the picture of the desired item.  Eventually, these sentences are expanded through adjectives and verbs.
  • Phase 5: Children learn to use pictures to answer questions.
  • Phase 6: Children expand sentence formation to make general comments.

You can buy communication picture sets here and here!

To read more about PECS, please see the National Autism Resources Picture Exchange Communication System (PECS) webpage!

Video examples of PECS sessions can be seen here:

 

Discrete Trial Training (DTT)

DTT uses ABA methods to teach children discrete skills one at a time, then assembles those discrete skills into to perform a single skill or behavior [3].

DTT is useful in cases where the behavior is not apparently complex, but where being able to adopt the behaviors all-at-once would be difficult using other methods of ABA [6].

    • People with more prominent autistic traits might benefit from DTT for simple behaviors, such as asking someone if they want to play.
    • Learning the sounds of individual words or learning how to play with others could require separate discrete trials.

Treatment is mainly instructor-initiated rather than patient-initiated.

To learn more about DTT, please read What is Discrete Trial Training?

Pivotal Response Training (PRT)

PRT focuses on arranging a child’s environment to promote the use of certain items and then provides opportunities for the child to use those items in natural play. PRT therapy is tailored to the needs of each child and focuses on specific areas of child development, such as motivation, initiation of social interactions, self-regulation, and responding to multiple cues.  PRT is thought to indirectly improves other areas of social skills, behavior, and communication.

To be successful, it is helpful if the patient’s entire family adopts PRT “lifestyle.” Meaning that for best results, the child’s family should consistently use PRT techniques.

For more information about PRT, visit Autism Speaks Pivotal Response Treatment

 

Sensory Integration Therapy

Sensory integration therapy focuses on 3 basic senses: tactile (touch), vestibular (balance), and proprioceptive (body-awareness; internal stimuli).  It works on the premise that when one or more senses are over- or under-reactive to stimulation, cultivating awareness of how an individual responds to stimuli can reduce over-responsiveness [9].

Goals of Sensory Integration Therapy:

  • Provide the child with sensory information in order to “train” the central nervous system to be less responsive.
  • Teach the child strategies for processing and responding to sensory information.

Sensory Integration Therapy works by:

  • Using physical activities and exercises to help children learn to interpret and use sensory information more effectively.
  • Evaluation and treatment is performed by occupational therapists and/or physical therapists.
  • Sensory integration therapy is designed to be part of wider programs that also includes communication, behavioral, and educational therapies.
  • To learn about occupational therapy and sensory integration therapy can work together, please the How Occupational Therapy Helps with Sensory Integration Issues.

 

Speech Therapy

Speech therapy can assess and treat communication disorders.  By improving specific areas of communication, speech therapy is able to improve overall social skills in people with autism.

A speech therapist can help people with autism by:

  • Strengthening facial muscles
  • Articulating speech sounds
  • Understanding body language
  • Matching facial expressions to emotion
  • Responding to questions
  • Modulating tone
  • Speech therapists can also aid with feeding and swallowing challenges.

After evaluation by a speech therapist, an individualized plan is formed for patients, and therapy sessions can begin. Sessions can occur in several settings:

  • Private clinics
  • Schools – as part of an Individualized Education Program (IEP)
  • Home
  • Community

Sign language, PECS, and other forms of alternative augmentative communication can also be a part of treatment.  Alternative Augmentative Communication (AAC) is:

  • AAC is communication that is used in place of speech when language is absent or not functional.
  • AAC is augmentative in that is can be used to supplement existing speech.
  • In ASD, AAC improves existing language and is a tool to help patients acquire expressive and receptive language.
  • AAC can also help with literacy development.

To learn more about speech therapy, see the American Speech-Language-Hearing Association (ASHA)-Certified Speech-Language Pathologist and Autism Spectrum Disorder flyer: https://www.asha.org/siteassets/uploadedfiles/asha-slp-asd-flyer.pdf

Please note: children don’t need need to be diagnosed as autistic to work with a speech therapist.  If you are waiting for a diagnosis or ABA, working will a speech therapist can be a good way for children to build skills in the meantime.

 

Floortime

Floortime is an alternative treatment to ABA therapy that focuses on 6 key milestones in childhood development to improve autism symptoms [13].  The 6 key milestones of floortime are:

  • Self-regulation and interest in the world
  • Engagement in relationships
  • Two-way communication
  • Complex communication
  • Emotional ideas
  • Emotional thinking

Through focusing on emotional development, floortime is thought to work indirectly on speech, motor, and cognitive skills.  Therapy sessions involve therapists and parents engaging children through enjoyable activities that emphasize back-and-forth play and expand circles of communication. Back-and-forth play develops the foundation for shared attention and engagement.  Providers are able to continually monitor the child’s development, forming a better picture of where the child is developmentally.

Sessions also include training for parents and caregivers on how to help children with ASD maintain focus. Parents are more hands-on in floortime therapy and receive guidance on how to update play for their child’s individualized needs from a therapist.

Floortime therapy can be done child psychologists, special education teachers, speech therapists, and occupational therapists.

Parents can also learn techniques through workshops provided by Greenspan Floortime for Parents

To learn more about floortime, please see Explaining DIR/Floortime.

Verbal Behavior Therapy

Using the principles BF Skinner and ABA methods, verbal behavior therapy teaches communication and language skills by helping autistic children connect words with their purpose.

Verbal Behavior Therapy uses a method call “errorless learning.” In errorless learning, therapists encourage patients to use words by providing prompts.  For instance, if a therapist is trying to teach a child to ask for a book, the therapist may start by hold the book in front of the child and say “book.”  Over time, rather than say “book,” the therapist may prompt the child by making a “b” sound.  The goal of this training is to have the child ask for the book unprompted (having associated the word “book” with the physical object).

  • The prompts are reduced overtime, and the student eventually no longer needs prompting to provide the correct response.
  • Most programs involve at least 1 to 3 hours of therapy per week, which is a lesser time commitment than most other intervention programs.

To learn more about Verbal Behavior Therapy, please see Autism Speaks Verbal Behavior Therapy

For an example of a Verbal Behavior Therapy session, please watch ABA Therapy – Verbal Reasoning Skills.

Work Cited