Autism is a severe disruption of normal developmental processes that occurs in the first three years of life. It is manifested in impaired language, cognitive, social and adaptive functioning. These essential skill deficits cause children to fall progressively farther behind their typical peers as they grow older. The cause is unknown, but evidence points to physiological and neurological abnormalities.

Children with autism generally do not learn in the same way that children normally learn, because, in part, they lack the fundamental skills which enable them to acquire and process basic information. They appear to lack understanding of simple verbal and nonverbal communication, are often affected by sensory over-stimulation or under-stimulation, and seem withdrawn in varying degrees from people and the world around them. They are often preoccupied with certain activities and/or objects, which further interferes with their ability to acquire skills and learn from information that is available to them. These difficulties result in significant delays in their development of language, play and social skills, including their failure to notice and learn through imitation of their peers.

Despite the disruption of typical learning processes, behavioural scientists have utilized principles and procedures of learning theory to develop effective treatment methodologies for teaching children with autism. Four decades of research conducted by Dr. Ivar Lovaas and his associates at UCLA, as well as other behavioural researchers, have empirically demonstrated the effectiveness of intensive behavioural treatment for children with autism. In particular, early intervention can significantly improve the abilities of these children to learn and function more adaptively. In his 1987 follow-up study, Dr. Lovaas reported that 17 out of 19 children, who received intensive behavioural treatment, significantly improved their social, self help, play and communication skills, including the development of functional speech. Furthermore, 9 of the 19 children were able to successfully complete first grade in regular education classes and were indistinguishable from their peers on measures of IQ, adaptive skills, and emotional functioning. A 1993 follow up study by McEachin, Smith and Lovaas showed that treatment gains were maintained more than six years later and eight of the children continued to progress in regular education classes without support.

The children in this study were three years old and younger when treatment was started. They received an average of 40 man-hours per week (some received more that 40 hours, some received less) of individual treatment provided by UCLA undergraduates who were supervised by graduate students and psychologists. Treatment lasted an average of two years or longer.

Applied Behaviour Analysis (ABA) with autistic children has experienced a return to popularity over the past six years. This renewed interest, in large part, can be linked to the publication of Catherine Maurice's book, Let Me Hear Your Voice, in which she chronicles the treatment of her two autistic children. Like many professionals and parents, Ms. Maurice initially had a dim view of behavioural intervention. She believed it to be an extremely negative and inflexible procedure. Moreover, she thought that behavioural intervention had limited effectiveness and often produced overtly mechanical responding in children. Her experience, however, proved to be far different. She found that behavioural intervention can be employed positively with a high degree of flexibility. Most importantly, the intervention proved to be highly effective.

Ms. Maurice's story gave hope to parents who had been led to believe, often by professionals, that autistic children will always remain severely impacted by their diagnosis. With hope and a direction, parents throughout the world started setting up intensive behavioural programs. Parents also started demanding that schools and state agencies use ABA with their children.

Although the tremendous popularity of ABA is recent, ABA is not a new procedure. Critics of behavioural intervention often contend that it is an "experimental" procedure with limited empirical evidence of its effectiveness. Lovaas (1987) and McEachin, Smith and Lovaas (1993) are often cited as the only two investigations to show that behavioural intervention with autistic children is effective. In fact, ABA is based upon more than 50 years of scientific investigation with individuals affected by a wide range of behavioural and developmental disorders. Since the early 1960's, extensive research has proven the effectiveness of behavioural intervention with autistic children. The research has shown ABA to be effective in reducing disruptive behaviours typically observed in autistic individuals, such as self-injury, tantrums, non-compliance and self-stimulation. ABA has also been shown to be effective in teaching commonly deficient skills such as complex communication, social, play and self-help skills. As early as 1973, Lovaas and his colleagues published a comprehensive study showing ABA to be effective in treating multiple behaviours with multiple children.

Although the work by Lovaas is the most frequently cited, there is other evidence that ABA can result in substantial benefit. Harris and Handleman (1994) reviewed several research studies that showed that more than 50% of autistic children who participated in comprehensive preschool programs using ABA were successfully integrated into non-handicapped classrooms, with many requiring little on-going treatment.

Our directors were intimately involved in the treatment program developed at the UCLA Young Autism Project during the period of 1975-1987. Our current work incorporates the knowledge gained from the University research clinic and combines it with our more recent experience delivering services in community based settings. As knowledge about effective behavioural treatments continues to advance, we have also made innovations to increase accessibility to greater numbers of children in a variety of settings. We have extended the application of this specialized teaching methodology to children who are older. While it is clear that the optimal time to begin intervention is at the preschool age, there are many older children who have greatly benefited from intensive behavioural treatment. The collaborative efforts between families, public and private school programs, and other service agencies have made it possible to offer effective treatment to a wide number and variety of children with differing needs. For example, there are many families who reside in areas where qualified professionals with expertise in the treatment of autism are not locally available. However, individuals possessing the personal qualities and motivation can, and have been, recruited, trained and supervised in the provision of effective services.

We emphasize a positive and systematic approach to teaching functional skills and reducing behaviour problems. We emphasize creativity and flexibility, capitalizing on the resources available for each individual child. While we have found certain teaching techniques to be consistently effective, we also recognize that each person working with a child has their own style and unique contribution to make to the educational treatment process. In the initial treatment phases, it is important that all members of the team adhere consistently to the smallest details of the teaching plan. As the child masters skills, it becomes important to deliberately increase variability in order to facilitate generalization to all persons and settings in the child's natural environment.

While most research on intensive behavioural treatment has been done exclusively with very young children, our experience has demonstrated that older children can benefit substantially from a similar treatment format. We make modifications in the treatment plan according to the age and developmental level of the person, taking into account the need for teaching functional and age-appropriate skills, effectiveness and suitability of reinforcers, severity of disruptive and interfering behaviour, and realistic expectations for achievement.

We have extensive experience working with person of all ages in a variety of settings including home, schools, vocational and employment services, and residential care and training. Through the years we have served individuals with a broad range of needs. One group we have given special attention to is older children. This group requires special treatment to address their unique needs. Development of coping skills to deal with frustration, self-esteem and complex social skills are critical. Additionally, strategies designed to deal with interpersonal issues, such as depression, social problem solving and conflicts with family and friends, are often necessary.

In determining the intensity or number of treatment hours, the child’s daily schedule should be considered in order to determine an appropriate balance between periods of intensive teaching and less intensive (but still structured) activities, as well as allowing for the child's need to have periods of free time. Besides the number of hours of 1-to-1 teaching, you should consider the quality of teaching and the degree of structure provided outside the formal therapy hours. Research shows that many children will do best with 30 or more hours per week of direct instruction. The length of therapy sessions should be adjusted to provide maximum benefit. Generally it is recommended that sessions last two to three hours. Once a child is spending part of the day in school, it may be advisable to reduce the treatment hours at home.

 THERAPY FORMAT

Teaching is a process which will change over time. Initially, the duration of time spent in formal discrete trial teaching will steadily increase as your child becomes comfortable with intervention. In later stages, the amount of time spent in discrete trials will decrease as time in other types of instruction increases (e.g., group and incidental teaching). Curriculum emphasis will also shift during the course of therapy. However, therapy's general structure will remain the same. Intervention will be a combination of programs designed to increase communication, play, social and self-help skills. Every child's program is individualized to his particular needs. However, the following is an example of how time might be allocated in a typical three-hour therapy shift:

20 minutes Structured Play (inside)

80 minutes Language (short breaks throughout: 0-20 minutes language; 5-10 min. play; 0-20 minutes language; 5-10 min. play; etc.)

30 minutes Self-Help Skills

30 minutes Structured Play (outside)

20 minutes Record Completion and Debriefing

Any part of this distribution may be increased or decreased dependent upon the child's age, the stage of therapy, and school requirements.

Applied Behaviour Analysis is the major treatment modality employed in the program. Although many different techniques are used as part of treatment, the primary instructional method is discrete trials. Discrete trial teaching is a specific methodology used to maximize learning. It is a teaching process used to develop most skills, including cognitive, communication, play, social and self-help skills. Additionally, it is strategy that can be used for all ages and populations.

IT IS A TEACHING STRATEGY THAT IS USED NOT ONLY FOR TEACHING LANGUAGE, NOR IS IT ONLY EMPLOYED FOR CHILDREN WITH AUTISM. IT IS SIMPLY GOOD TEACHING!!!

The technique involves: 1) breaking a skill into smaller parts; 2) teaching one sub-skill at a time until mastery; 3) allowing repeated practice in a concentrated period of time; 4) providing prompting and prompt fading as necessary; and 5) utilizing reinforcement procedures.

A teaching session involves numerous trials, with each trial having a distinct beginning and end, hence the name "discrete". Each part of the skill is mastered before more information is presented. In discrete trial teaching, a very small unit of information is presented and the student's response is immediately sought. This contrasts with continuous trial or more traditional teaching methods which present large amounts of information with no clearly defined target response on the student's part.

Other techniques used in treatment may include behaviour management, crisis intervention, structured teaching interactions and more traditional counseling.

Initially teaching is done in an environment that will lead to early success. Sometimes that may mean a controlled environment with reduced distractions. However, teaching must quickly be extended to everyday settings. Not only is this more natural but it also promotes transferring learning to all settings. Therefore, therapy will occur THROUGHOUT the house as well as outside and in the community (e.g., the park, McDonald's, the market, etc.). If distractions pose a problem, it will be critical that we help the child learn to focus even in the presence of environmental interference. Children must be able to learn in varied environments where distractions naturally occur so as to prepare them for learning in typical settings such as school.

Teaching materials and reinforcers are critical to the therapy process. It is essential that parents have these materials ready when staff arrives. The program supervisor will help you in the selection of materials. Continued exposure to novel items in therapy improves the experience for both staff and child. Furthermore, reinforcers need to be varied and supplemented continually.

The intensive behavioural intervention curriculum has been developed through three decades of research. The content includes all the skills a person needs to be able to function successfully and to enjoy life to its fullest. It includes skills that most children typically do not need to be formally taught such as play and imitation. A strong emphasis is placed on development of speech and language, conceptual, and academic skills, as well as promoting play and social skills. However, as a child gets older, the emphasis shifts to practical knowledge and adaptive skills along with alternative means of communication if speech has not developed. The curriculum is developmentally sequenced so that easier concepts and skills are taught first and complex skills are not introduced until the child has learned the prerequisite skills. However, the process of program design and implementation cannot rigidly be expected to follow a fixed order. Although it is not the usual pattern, some children learn to read before they can talk. It is important to build on a child's successes and expand the utilization of existing skills as well as encourage the development of new ones. Some children may never learn to talk and will need an alternative means of communication. We utilize the child's areas of strength and build upon them as rapidly as possible, while simultaneously attempting to offset the areas of weakness. The teaching methods are based on elegant application of learning theory and have benefited from the clever innovations of thousands of individuals over the years. The approach is very pragmatic: if it works, stick with it; if it does not work, figure out how to fix it.

The team typically includes persons who assume different responsibilities. Discrete Trial Teaching is conducted by Program Specialists or Tutors. Case Management and Parent Training, typically two-three hours per week, is provided by Program Supervisors. Clinical Supervisors and the Program Directors provide overall supervision during child staffings at the clinic as well as during trainings and group and individual supervision meetings.

The primary and essential ingredients for a successful treatment team include: (1) Close family involvement; (2) Individuals (teachers and staff) who possess the personal qualities necessary to be a good behavioural instructor; (3) Training and supervision provided by a qualified clinician. Ideally, the team should include all individuals currently involved in the child’s educational program and those who may be newly recruited. This should include school personnel as well as other professionals who will be involved in the child’s ongoing treatment program.

FAMILY: The involvement of the family is critical in the treatment process. No one knows the child better nor cares more about his welfare than do his parents and they are the ones most affected by the child’s disorder. Parents spend a great deal of time with the child and are in a position to carry over teaching goals into everyday living situations. They can also provide some structured teaching sessions to the child. However, it is important to realize that living with an autistic child takes a heavy emotional toll and coordinating the treatment team is already a large undertaking.

The majority of intensive teaching should be provided by paid staff, volunteers or school personnel. This allows parents to have some respite and the remaining time spent with their child can be more enjoyable and productive. Parents can utilize the child’s "free time" to augment intensive teaching time, in developing play, social and self-help skills. Bath time, dinner, getting dressed, and feeding the family pet are just a few examples of everyday routines that offer opportunities for teaching. Outings to the park, grocery shopping, mailing a letter and visits to a relative's home are opportunities to generalize skills and work on improving behaviour. In this way the child's entire day becomes part of the treatment process and the parents become an integral part of the team.

STAFF: It is rare to find an experienced staff person who can step in and start working with your child on the first day. If you are working with an agency such as Autism Partnership, we can provide trained staff. While experience is a plus there are many other factors that determine whether a person will be a good behavioural interventionist. We look for people who are enthusiastic, eager to learn, reliable, and able to accept and incorporate feedback. Completion of a degree in psychology or special education is highly desirable, but families who have to recruit staff on their own have often had good results hiring students still in college. We recommend a team ranging from 2-5 staff, who can each work between 6 and 12 hours per week.

SUPERVISION: You will need a qualified person to lead the team. It takes years of training and experience to be able to train and supervise others in the implementation of behavioural programming. While there are common elements in the treatment of most autistic children, each child presents a unique challenge in designing and guiding the optimal learning process. The level of supervision necessary is based on a number of factors, including skill level of staff and parents, stage of treatment, complexity of programs required, number of treatment hours, etc. It is important that a qualified supervisor be involved on a regular, and as needed basis. Treatment may get "stuck" and the child’s progress impeded if there is not a qualified supervisor with sufficient expertise to effectively address these difficulties.

As the child learns, therapy will progress through different stages. Although the stages are not absolutely distinct, therapy can be described in three phases:

Beginning Stages involve getting to know your child. It is critical to establish a warm, playful and reinforcing social relationship. To help accomplish this goal the first month of therapy emphasizes identification and establishment of reinforcers, with much play and non-contingent delivery of reinforcers. Through creating a positive atmosphere, your child will be far more amenable to the teaching process and therefore proceed faster through therapy with less power struggles and disruptive behaviours. It is essential to determine your child's likes and dislikes as well as identifying their strengths and weaknesses. "Learning to Learn" is also a critical component of the beginning stage. The child needs to learn that cooperation with requests will result in immediate and frequent rewards. This further entails acquiring skills such as sitting and paying attention, remaining on-task in the teaching situation, being responsive to instruction, learning how to process feedback, and understanding cause and effect.

Middle Stages of therapy involve learning specific communication, play, self-help and social skills. Complex concepts are broken down into a series of steps that will be taught systemically. As the child moves through the program, there will be individualized adjustment of the curriculum to meet your child's needs. Therapy will be done as naturally as possible with a goal of increasing the child's ability to learn and function in natural settings. Children will be exposed to play dates and other social and community settings. Children are usually introduced to the school setting during this stage.

Advanced Stages involve progressively making therapy more natural and generalizable to the everyday environment. Working on more subtle social and play skills is often a component of this stage. Completion of integration into natural learning environments (e.g., school) also occurs at this time. Realistic recommendations for future placements and needs for treatment may be discussed.

The effectiveness of therapy must be continually evaluated. Staff will collect data daily. Information will be specific to both teaching programs and observations of behaviours. Regular clinic meetings are the forums for reviewing the effectiveness of intervention and making program refinements. Periodically we will evaluate the overall effectiveness of the program and make recommendations regarding the continuation of therapy.

Intensive Behavioural Intervention has been shown to successfully increase children's functioning in areas such as language, play, social and self-help. Naturally, however, there is a range in the degree of treatment outcomes. The result of treatment depends upon several factors such as age at onset of treatment and the child's cognitive capacity. Treatment is designed to bring out the child's fullest potential.

Although "recovery" would be everyone’s preferred outcome, research findings so far suggest that less than half of children who begin treatment before age three can achieve the very best outcomes. However, nearly all children in the controlled studies of Intensive Behavioural Treatment have made substantial progress (e.g., development of communication, social and play skills). It is difficult to determine in advance which children will respond most favorably to treatment. However, presence of communication skills is one important positive indicator. Typically, after three to six months of treatment we will have an idea of how quickly the child will progress in treatment.

Ron Leaf is a licensed psychologist who has over twenty-five years of experience in the field of autism. Dr. Leaf began his career working with Ivar Lovaas, while receiving his undergraduate degree at UCLA. Subsequently he received his doctorate under the direction of Dr. Lovaas. During his professional training at UCLA, he served as Clinic Supervisor, Research Psychologist, Lecturer, and Interim Director of the Young Autism Project. He was extensively involved in many of the Young Autism Project research investigations, contributed to The Me Book, and is co-author of The Me Book Videotapes, a series of instructional tapes offering training for teaching autistic children. He is co-author of A Work in Progress, a manual on behavioural treatment. Dr. Leaf has consulted nationally and internationally to families, school districts, day programs and residential treatment facilities. Dr. Leaf served as the Director of Straight Talk's Developmental Disabilities Services division for 15 years. This program provided residential and day treatment for adults with developmental disabilities. Dr. Leaf is also the Executive Director of Behaviour Therapy and Learning Center, a mental health agency providing treatment, consultation and related services to parents, program staff and school personnel.