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An Initiative of National Trust
for the Welfare of Persons with Autism, Cerebral Palsy,
Mental Retardation & Multiple Disabilities
Ministry of Social Justice & Empowerment, Government of India
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Interventions of Autism


There are several kinds of intervention of Autism. Many of them have been found useful and effective for children with Autism, while other methods do not have sufficient evidence of their applicability for all children with Autism. The interventions presented below are the ones that have received research and evidence based support from clinicians and practitioners across the world as well as in India. There are four main approaches which are as follows:

1. Developmental Approaches

2. Behavioural Approaches

3. Cognitive Approaches

4. Therapeutic Approach

 
Developmental approach to Intervention:

In a developmental approach, the intervention is based on the neuro-typical developmental sequence in children. The aim of these interventions is to identify the developmental level that the child with Autism is currently functioning.

The parent/educator sets the goals for intervention on the next developmentally appropriate skills he/she should achieve. The intervention is child centric; this means that it is tailored to each individual child and does not depend on the age of the child but his/her level of skills. In most of these interventions toys and learning materials suitable to the child's level of functioning are provided. The adult is instructed to follow the child's lead. The child is free to play the way he wants to while and the adult's role is that of a facilitator. For example, if a child selects a toy, the adult may demonstrate what can be done with it. If the child shows interest in the activity, the adult may provide prompts to the child. Unlike behavioural approaches, the developmental interventions have a much more naturalistic approach to the setting and steps which are followed.

Different developmental interventions for Autism include:

  • Floor time
  • Relationship Development Intervention
  • ComDEALL
  • Pre-school Autism Communication Therapy
  • Denver Early Start Model
  • Hanen
  • Multiple Intelligence
Floortime: The Developmental Individual Relationship based (DIR) Model (link) given by Stanley Greenspan provides the framework for Floor time. The DIR model describes six milestones namely: 1)self regulation and interest, 2) intimacy, 3) two way communication, 4) complex communication, 5) emotional ideas, and 6) emotional thinking as crucial to child's development. The objectives of this model is to build healthy foundations for social, emotional, and intellectual capacities rather than focusing on skills and isolated behaviours. Floortime is implemented in three phases. In phase 1; professionals conduct Floortime with the child; in phase 2; parents observe Floortime being done with their child, and finally in phase 3; parents change their style of relating to the child with regard to a given milestone. The intervention aims at identifying and teaching the basic milestones that the child may have missed in the process of development and transferring these skills to parents. This intervention is carried out in one to one sessions where parents are in partnership with therapists.

Relationship Development Intervention (RDI): The RDI is based on the premise that children with Autism can learn to develop emotional relationships with others if taught this in a systematic manner. The Dynamic Intelligence Model by Steven Gutstein (link) provides the framework for RDI. Dynamic intelligence consists of a variety of cognitive abilities such as flexibility of thought, coping with environmental changes, thinking from different perspectives, simultaneous processing of information etc. In typically developed children these abilities develop as they are encouraged by their parents and family to engage in social interactions. The Dynamic Intelligence model directly addresses communication and socio-emotional behaviour deficits seen in children with Autism.

RDI aims to motivate and provide ways to a child so that he/she learns the social behaviours of understanding and sharing of experiences, emotional relationships, and self regulation. RDI is a family-based intervention in which professionals show parents how to modify their interaction and communication style to suit the functioning level of the child. Like Floor time, RDI too is delivered in phases. In Phase 1, the professionals observe the child and the quality of parent-child interaction. During Phase 2 the professionals demonstrate how to help a child participate in activities so the child becomes a 'cognitive apprentice' to the parents. Finally in Phase 3 when the child has learned his/her new role the parents can introduce developmentally appropriate cognitive and social activities.

Communication DEALL (Developmental Eclectic Approach to Language Learning)

This is an indigenous early intervention program within the developmental framework/ approaches. It is an interdisciplinary program with young children being trained by a team of occupational therapists, speech-language therapists, educators and psychologists; for a few hours on a daily basis across one to three years, with the target of mainstreaming them in regular schools by 6 years of age. This program works with a group of children with Autism to help them acquire skills that are the foundation of learning. See: http://www.communicationdeall.org/#!program/c1lki

Pre-school Autism Communication Therapy (PACT).

The principles of PACT derive from research in language development. The approach targets the main difficulties in shared attention, understanding and social communication that children with Autism have. It is aimed at children whose language level is at a preverbal or an early stage. The program focuses on changing the interaction between the child and the parent by using video feedback of parent –child plays sessions and is tailored individually to each child. In a step wise manner it works to improve shared attention, communication intent and the quality of language used by the child with Autism. PACT can be delivered to children regardless of their age though it is most effective in the pre-school years.

The Early Start Denver Model (ESDM):

This intervention is a play-based intervention which focuses on helping children with Autism develop play skills, relationships and language. This is based on the Denver Model and Pivotal Response Training can be delivered in various ways; either as a one on one intensive session, in a preschool setting or at home. The Early Start Denver Model emphasizes the development of play skills, relationships and language and helps increase the child’s interest in others by building a strong positive relationship between the child with Autism and their parents. The ESDM is ideal for the pre-school age group.

Hanen

“The More than Words” program is another developmental approach which targets social communication difficulties of children with Autism. There are program for both younger and older children and are delivered to a group of parents in a small group setting. The program teaches the parent to respond appropriately to their child’s communication attempts.

Multiple Intelligence

The theory of Multiple Intelligences (MI) was put forward by Howard Gardner, an American developmental psychologist. The MI approach could help children with Autism maximise their potentials. (sani Pls. Link the following files)

Multiple Intelligence

Multiple Intelligence and Disabilities (MInD)

Emotional Intelligence

Inclusion

Understanding the potential of persons with autism with the lens of Multiple Intelligences

II. Behavioural Interventions

Behavioural interventions aim to teach a child positive behaviours and reduce or eliminate inappropriate behaviours. The desired behaviour is broken down into small, achievable tasks which are then taught in a very structured manner to the child.

Applied Behaviour Analysis (ABA) based Interventions:

ABA is the application of behaviour theories to education of children with Autism. ABA is based on the premise that environment (both physical and social) plays an important role in the manifestation of an individual's behaviour; and that a behaviour that is rewarded or praised is more likely to be repeated. ABA uses a range of techniques (such as shaping, reinforcement, extinction, stimulus control, motivation) to teach new behaviours, and modify and/or terminate unwanted behaviours. ABA is a widely researched method of intervention for Autism and other developmental disabilities. It has been found effective in developing social, communication and self-help skills in children with Autism. Commonly used ABA based interventions are:

  • Discrete Trial Training (DTT)
  • Pivotal Response Training (PRT)
  • TEACCH (Treatment and Education of Autistic and other Communication handicapped Children)
  • Analysis of Verbal Behaviour (AVB)


Discrete Trial Training (DTT): Also known as the Lovaas (link the given URL method (Also :see http://petemolino.com/uploads/Smith_-_DTT_in_Tx_of_Autism.pdf, http://en.wikipedia.org/wiki/Lovaas_model‎)

DTT is a specific and systematic method of the ABA. It is used in one to one teaching situations. The learning task is broken into small steps and the child is prompted to respond to each step correctly. Every attempt that the child makes towards learning the task is rewarded. Trials are repeated with gradual fading of prompts as the task is learned. DTT has been widely used for teaching compliance, concepts, communication and play skills to children with Autism. DTT protocol recommends an environmental structure when teaching a child with Autism. DTT is often used with young children with Autism

Pivotal Response Training (PRT): This is used to teach behaviours that are developmentally appropriate. Though based on ABA, it uses a naturalistic environment for teaching the child. Hence, the focus is to develop communication and play skills required in the child's normal environment. The teaching procedures demand the use of prompts and cues to help the child as he/she attempts to learn the task. The child's efforts are rewarded. PRT is a suitable method for pre-school children with Autism.

Treatment and Education of Autistic and other Communication Handicapped Children(TEACCH):

TEACCH is designed to meet the specific needs of individuals on the Autism spectrum. It is based on the core deficit that children with Autism function best in structures and predictable environments. This method relies on the creation of a structured learning environment (a teaching-learning area that is uncluttered and is relatively free of elements that may distract children and which has distinct boundaries for doing certain activities); providing visual schedules (visual cues that indicate to the children what to expect throughout the day), planning of work systems that indicate what is expected from children in a specific area; and organization of tasks in such a way that each task is visually represented and contains a clue as to how it should be done. TEACCH recommends the use of prompts, and reinforcing a response as the child learns to do the task. While DTT and PRT are suitable for young children and are used for developing cooperation, communication, play and basic conceptual skills, TEACCH may be used with children as well as adolescents and young adults with Autism.

Analysis of Verbal Behaviour (AVB): Also referred to as verbal behaviour analysis, the AVB is an application of ABA principles to develop verbal behaviour. Verbal behaviour is a group of functional units of language that develop in reinforcing conditions (for e.g. if a child says 'car', the adult gives a toy car. This would reinforce the child to use the word in future too.) The reinforcers come from the environment and the people who interact with the child. The functional units of language are called verbal operants. The commonly used verbal operants in the AVB are:

Mand: the ability to request/ask for things that one wants,

Tact: the ability to name/label items, actions and feelings),

Intra-verbal: the ability to answer questions or give expected responses), and Echoic (the ability to repeat what one has heard).

The AVB protocol recommends that each verbal operants be taught using the techniques of shaping, reinforcement, prompts and error correction.(AVB is a recommended intervention for school going children who are learning to communicate verbally or non-verbally.)

III. Cognitive approach to intervention: Cognition deals with 'thinking'. It requires the ability to process information that comes from around us. It is the ability to perceive and correctly interpret the signals that one's sensory organs are sending to one's brain. Cognition also involves the ability to automatically organize various units of factual and emotional information in order to make decisions and appropriate responses. (for e.g. a typically growing child knows how to modify his/her responses according to environment he is in. The child's response to a request from a teacher may be different from that to a request from a sibling.)Because of impairments in sensory processing and integration, children with Autism are often unable to categorize information. Hence, such cognitive skills as comprehending and reacting appropriately to people's communication, understanding concepts, predicting outcome from the information available, understanding others thoughts and feelings, and engaging in meaningful conversation etc. are poorly developed. Cognitive interventions are designed to use the child's processing to help him/her understand their personal responses and ultimately help modify these responses to suit the situation. The interventions under this approach include:

  • Social Story
  • Mind Reading
Social Story:

A social story facilitates social understanding between children who have Autism and those who interact with them. An intervention method designed by Carol Gray(link). Social Story describes a social situation along with appropriate responses. Individualized for a child, a Social Story is a short narrative (between 20 to 200 words) defined by specific characteristics that describes a situation, concept or social skill in terms that are meaningful to the child. The result is often a renewed sensitivity of others to the experience of the child with Autism, and an improvement in the responses of the child. Social stories provide a child with accurate information about those situations that he/she may find difficult or confusing. The situation is described in detail and focus is given to a few key points: the important social cues, the events and reactions the child might expect to occur in the situation, the actions and reactions that might be expected of him/her, and why. The goal of the story is to increase the child’s understanding of different situations, make him/her more comfortable in, and possibly suggest some appropriate responses for the situation in question. Generally, Social Stories are written using four types of sentences: (a) descriptive sentences, which are accurate, free statements of facts, which describe what happens, where the situation occurs and why; (b) perspective sentences, which state the thoughts, feelings, belief, opinion, and motivation of people other than the child with Autism; (c) directive sentences, which describe the appropriate behavioural response for a given situation; and (d) control sentences, which help in determining a response by recalling and applying information. A Social Story usually includes 2 to 5 descriptive, perspective, or control sentences for every directive sentence. For some children, social stories may incorporate pictures or symbols.

Mind Reading:

Designed by Simon Baron-Cohen, Mind Reading is an educational program to address the social-communication deficits experienced by children with Autism. These deficits arise from their inability to "read" or understand people's facial expressions and/or tone of voice in which something is being said. Not having understood what is being said and how, the children either do not respond or give inappropriate responses in social situations. Mind Reading helps children with Autism understand emotions. The program is available in the form of an interactive DVD, http://www.jkp.com/mindreading/demo/index.php, mind reading resources available online at http://www.jkp.com/mindreading/buy/) and contains 412 emotional concepts. The concepts are enacted by actors who use their faces and voice in the context of stories. The Mind Reading resource has 3 parts: the Emotion Library, where the emotional concepts are presented visually; the Learning Centre, which includes activities and quizzes to consolidate learning; and the Games Zone, where the child can play motivating games to practice what has been learned. As an intervention, Mind Reading is suitable for both children and adults with Autism.

IV. Therapeutic interventions: The complex nature of Autism entails use of different interventions simultaneously. Thus the interventions described above are often supplemented by that aim to enhance communication and sensory processing skills. Alternative and augmentative communication and sensory integration therapy are among the most commonly used therapeutic interventions for children with Autism in India.

  • Picture Exchange Communication System (PECS)
  • Makaton
  • Visual Strategy


Picture Exchange Communication System (PECS)

Designed by Bondy and Frost, PECS is a system of AAC developed to aid functional communication in children with Autism and other special needs. PECS allows children with Autism who have little or no communication abilities, a means of communicating non-verbally. Children using PECS are taught to link a picture of a desired item in exchange for that item itself. By doing so, the child is able to initiate communication. The child with Autism can use PECS to communicate a request, a thought, or anything that can reasonably be displayed or symbolized on a picture card. The PECS training protocol is based on Skinner's verbal behaviour theory. PECS teaches the use of verbal operants through picture exchange. PECS works well in the home or in the classroom.(PECS picture cards may be bought online from http://www.pecs-unitedkingdom.com/shop/. Other picture cards may be used following the PECS recommended protocol. Line drawings and pictorial symbols are available at http://www.do2learn.com/picturecards/FunctionalCommunication/index.htm. Indian Institute of Cerebral Palsy (http://iicpindia.org/ has produced Indian picture cards that can be used for PECS.

Makaton

Designed by Margaret Walker, the Makaton Language Program is a multi-modal system of AAC. It uses signs and symbols to aid communication. It is designed to support spoken language and the signs and symbols are used with speech, in spoken word order. Use of signs and symbols with speech helps a child with Autism to comprehend what is being said. The manual or pictorial mode augments oral communication. A non-verbal child learns to communicate using the signs or symbols initially, and may drop their use once oral expressive language develops. The Makaton Language Program provides (a) core vocabulary that includes words and language concepts that are required for daily use (b) resource vocabulary of words that are not used regularly but are required in specific situation, events or functions, and (c) teaching procedure. Makaton is a suitable program for children and adults with Autism Makaton resources (Indian Version) are available with Makaton India, Mumbai, ( See address). Several schools for children with Autism and intellectual disabilities across India have used Makaton with their children. Makaton India conducts training workshops for professionals and parents.

Alternative and Augmentative Communication (AAC):

Many children with Autism have severe impairments in verbal and non-verbal communication. Nearly 50% of the children are non-verbal and have insufficient ability for communication and social interaction. This may be due to a delay in development of core skills for language development such as eye contact, joint attention, imitation, turn taking and using gestures. AAC addresses the needs of children who are unable to communicate or express themselves using standard communication tools, such as spoken and written language. Any system that attempts to compensate (either temporarily or permanently) for the impairment and disability patterns of children with severe communication problems may be called AAC. The AAC strategies used for children with Autism are (a) gestures and manual signs (b) pictographic symbol sets/systems, and (c) speech generating devices for synthesized and digitalized speech output. Some AAC systems commonly used for Autism intervention in India are described below.

Visual Strategies

Research studies have indicated that children with Autism are visual learners; that is they are able to process visual information better than information that is purely in auditory form (that is speech). This means that they understand what they ‘see’ better than they understand what they ‘hear'. Visual tools and supports facilitate acquisition of communication skills in such children. Visual Strategies are essentially the use of such visual tools and supports that we employ to enhance the communication process. Ranging from facial expression, body language, objects, and pictures to posters and charts, visual tools promote effective receiving, processing, action and expression. Since the information presented through visual tools is static and predictable it enables the child with Autism to rely on recognition rather than memory, to receive language input and generate language output. Pictures, symbols, cue cards, visual schedules, visual activity schedules, task cards etc. are routinely used as strategies when teaching children with Autism. For example, a cue card may be used for reminding a child about a rule/expected behaviour, e.g. a teacher may use a green flash card to indicate to a child with Autism, when it is his turn to participate in a given activity. Displaying classroom schedule in picture form helps a child understand the daily time table. Visual activity schedules helps develop independent work behaviour without repeated reminders from teacher/parent.

Sensory integration Therapy (SIT):

Sensory integration is the process of assimilating and organizing the messages received from the nervous system and turning them into appropriate motor and behavioural responses. Children with Autism often have difficulties in processing information that comes to brain through the senses, and this interferes with the ability to comprehend what is going on in the environment. Sensory integration dysfunction can lead to motor clumsiness, behavioural problems, anxiety, depression, academic failure, and a host of other problems. Sensory integration dysfunction may result in conditions known as 'hypersensitivity' and 'hyposensitivity'. When the brain interprets certain sensory information too strongly, the child is hypersensitive to the sensory input. Ordinary noises from the environment may seem frighteningly loud and scary, and mildest of touch may be unbearable. On the other hand, information that is interpreted too weakly by the brain may lead to hyposensitivity where the child may seek out more of the stimulus

A child who is hyposensitive to smell may want to sniff deeply at perfume or shampoo bottles. A child may not notice a cut or bruise if he/she is hyposensitive to touch or pain. SIT is aimed to the balance the input from the senses. For a hyposensitive child who requires more input to feel satisfied and function well, healthy and positive play activities that provide such inputs may be introduced during SIT. Alternatively, for a hypersensitive child, gentler forms of play may be given to ensure that the child is able to adjust to the input. The therapy targets tactile, vestibular and proprioceptive senses. These senses are interconnected and are also connected with other systems in the brain. The tactile system is involved in sending such information as touch, pain, temperature, and pressure. The tactile system helps in perceiving the environment as well as protecting from it. Impairments in the system can result in a child being ‘tactile defensive’ and unable to tolerate light touch, refusing to wear certain clothes or co-operate during haircut etc. The vestibular system is concerned with the ability to perceive movement and position of the head. Vestibular dysfunction may cause some children to fear simple activities as swings, slides, ramps etc. while some other children may seek intense vestibular experiences such jumping, spinning, and body whirling.

The proprioceptive system provides information on movement of muscles, joints and tendons, and a subconscious awareness of body position. An impairment in the proprioceptive system leads to motor planning problems, clumsiness, odd body posturing, and resistance to trying new motor movements. The child may appear impulsive, distractible, and may have problems in adjusting to new situations. SIT is carried out by qualified occupational therapists. A thorough assessment of the child's sensory processes is done to ascertain strength and difficulties. The therapy aims to (a) provide the child with sensory information which helps organize the central nervous system, (b) assist the child in inhibiting and/or modulating sensory information, and (c) to enable the child in processing a more organized response to sensory information.

Autism intervention is a growing field. There are many intervention methods besides those mentioned above, that are being used with children with Autism. Some of these interventions have evolved as a response to parental anxiety and need to search for a cure for their child. Diet therapy, auditory integration therapy and animal therapy etc. are examples of such interventions. Though popular among some parents and professionals, research studies have not conclusively established their efficacy as intervention for Autism. Hence, these interventions have not been included here.

How do parents decide what is good for their child?

The decision about intervention depends on factors such as the age, functioning level and specific needs of your child, and the availability of professionals.

References:

  • Dawson G. Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010;125(1):17-23.
  • Green J, Charman T, McConachie H, Aldred C, Slonims V, Howlin P, et al. Parent-mediated communication-focused treatment in children with autism (PACT): a randomised controlled trial. Lancet. 2010 Jun 19; 375(9732):2152-60.
  • Lal,R. & Lobo, S. (2007) Discrete Trial Teaching and Development of Pre-Learning Skills in Intellectually Impaired Children with Autism Journal of Rehabilitation Council of India Vol. 3 no 2 pp 15-23
  • Lal, R. (2010) Effect of Alternative & Augmentative Communication on Language and Social Behavior of Children with Autism Educational Research and Review Journal Vol. 2 No.1 pp119-125
  • Lal, R. & Bali, M. (2007) Effect of Visual Strategies on Development of Communication Skills in Children with Autism Asia Pacific Disability Rehabilitation Journal Vol. 18 no 2 pp120-130
  • Lal, R. & Ganesan, K (2011) Children with Autism Spectrum Disorders: Social Stories and Self Management of Behaviour British Journal of Educational Research 1(1): 36-48
  • Lal, R. & Shahane, A (2011) TEACCH Intervention for Autism. In Williams, T.(Ed.) Autism Spectrum Disorders: from Genes to Environment pp169-190 InTech Web Publisher, Croatia
  • Lal, R & Chhabria, R. (2013) Early Intervention of Autism: A case for Floor time Approach. In Fitzgerald M (Ed.) Recent Advances in Autism Spectrum Disorders Volume 1 pp 689-715 InTech Web Publisher, Croatia
  • Bondy, A. & Frost, I. (2002) A Picture's Worth: PECS and Other Visual Communication Strategies in Autism. Bethesda, MD: Woodbine House
  • Ayers, A. J. (1979) Sensory Integration and the Child. Los Angeles, Western Psychological Services
  • Koegel, L.K., Carter, C.M., & Koegel, R.L. (2003) Teaching Children with Autism Self Initiations as a Pivotal Response. Topics in Language Disorders 23(2) pp 134-145
  • Baron-Cohen, S. (2003) The Essential Difference: The Truth about the Male and Female Brain. New York. Basic Books
Makaton India
901 B-3 Whispering Palms
Lokhandwala Complex
Akurli Road
Kandivali (e)
Mumbai 400101
India
tel: 884 1115/414 2905
email: makaton@rediffmail.com
Contact person: Dr Rubina Lal

Medical Intervention

Medical interventions usually treat specific activities associated with Autism. They have shown beneficial effects in improving certain behaviours that children with Autism may have. Please see your doctor for any kind of medical treatment as it should be undertaken with his or her strict supervision.

Medication

Autism Spectrum Disorder ASD or commonly known as Autism is a neuro-developmental disorder. In other words, it is a condition in which certain brain networks or circuits are not properly developed, and this results in impairments in development of functions in many areas. There is currently no known cure or medicine that can treat Autism, however, there are some associated conditions which may be present in an individual that may require medical treatment.

Some examples are as follows:

Epilepsy or seizure disorder: About 25% of individuals with Autism develop seizures in their lifetime, most commonly in childhood & adolescence. Different types of seizures can occur, for example in the form of convulsions, or attacks of staring with impaired consciousness. These attacks can be controlled with appropriate anti-epileptic medication. Children with a convulsion or seizure will require a special test called an EEG (Electro-encephalogram) which is usually conducted in a specialist hospital. Based on the results the doctor will decide on the type of medication, dosage, timing of medication and duration of treatment. Like other drugs, these medications also have side effects. As a parent you must ask your doctor about the benefits and side effects of medication being prescribed.

Associated (or co-existing) psychiatric disorders: Individuals with Autism sometimes have symptoms of another psychiatric disorder over and above the features of Autism. Common examples of disorder which may co-exist are attention deficit hyperactivity disorder (ADHD), anxiety disorders, obsessive compulsive disorder and tic disorder. These conditions require careful evaluation by a doctor who is experienced in treating Autism. This may include a developmental paediatrician or a psychiatrist. When the symptoms are very persistent, severe and interfere with the activities of the child, appropriate medication may be required to manage these co-existing problems. As with all medications; insist on getting all the information on any medication that your child is prescribed.

Sleep difficulties: In some children, troublesome and persistent disturbances of sleep such as inability to fall asleep, repeated awakening, or sleep rhythm disturbances (for example sleeping in daytime and awake in night) can occur. There are specific medications that can help such children.

Difficult behaviours: Sometimes, children with Autism may have self-injurious behaviours, uncontrolled aggression or excessive stereotypes. Occasionally these behaviours interfere with other interventions that the child is being given. . If these behaviours cannot be addressed by providing predictability or occupational and sensory therapy, judicious and careful use of medication can be considered in such children and youngsters under close monitoring and supervision of a specialist.

Attention deficit hyperactivity disorder: characterized by persistent hyperactivity in many situations, easy distractibility, inability to concentrate on most activities, and impulsivity.

Anxiety disorders: are characterised by excessive, unwanted worrying and fearfulness.

Obsessive compulsive disorder is characterised by repetitive or ritualistic behaviours, such as arranging, cleaning, checking, washing, and excessive insistence on sameness; with the child typically resisting any attempt to change these behaviour.

Tic disorder are characterised by sudden, jerky, brief-lasting, repetitive movements of face (blinking, grimacing, pursing of lips), neck, shoulder, trunk, and making of repetitive sounds (such as clearing ones throat). These are different from the repetitive movements or behaviours that children with Autism may have; however it is often hard to tell these apart and hence should be evaluated by a specialist.

 Alternative interventions

There are a number of interventions and treatments that are being offered to parents of children with Autism. Many do not have good research evidence and some often are very distressing for the child with Autism. Below are listed some therapies which are not commonly accessible but may be available to you as a parent, along with the expert group’s consensus opinion on them.

The website has looked at current worldwide research evidence to understand what may help a child with Autism. The best evidence always compares a group of children who get a treatment against a matching group of children who did not get it. This is called a randomised control trial. There are very few of the following treatments which have had such trials conducted and hence our opinion is moderated by this lack of information.

1. Stem Cell Therapy:

This involves taking bone marrow from the child’s hip bone (often a painful procedure), and injecting it back into the blood of the same child. Often this treatment is followed by very intensive therapy at the centre providing the treatment. The International Society for Stem Cell research in it’s ‘Patient Handbook’ has issued the following statement (http://www.isscr.org/home/publications/patient-handbook ): ‘The International Society for Stem Cell Research (ISSCR) is very concerned that stem cell therapies are being sold around the world before they have been proven safe and effective. Stem cell therapies are nearly all new and experimental. In these early stages, they may not work, and there may be downsides.

Make sure you understand what to look out for before considering a stem cell therapy. Remember, most medical discoveries are based on years of research performed at universities and companies. There is a long process that shows first in laboratory studies and then in clinical research that something is safe and will work. Like a new drug, stem cell therapies must be assessed and meet certain standards before receiving approval from national regulatory bodies to be used to treat people.’

References:

  • Charles Arber andMeng Li “Cortical interneurons from human pluripotent stem cells: prospects for neurological and psychiatric disease” Frontiers in Cellular Neuroscience; www.frontiersin.org; March 2013 | Volume 7 | Article 10
  • “China’s stem-cell rules go unheeded” Health ministry’s attempt at regulation has had little effect. 12 APRIL 2012 | VOL 484 | NATURE | 149
  • Diseases”Guo-Li Ming, Oliver Bru ̈stle “Cellular Reprogramming: Recent Advances in Modeling Neurological The Journal of Neuroscience, November 9, 2011 • 31(45):16070 –16075
  • Flora M. Vaccarino, Hanna E. Stevens, ArifKocabas “Induced pluripotent stem cells: a new tool to confront the challenge of neuropsychiatric disorders” Neuropharmacology. 2011 June ; 60(7-8): 1355–1363. doi:10.1016/j.neuropharm.2011.02.021.
  • Flora M. Vaccarino, Alexander Eckehart Urban “The promise of stem cell research for neuropsychiatric disorders” J Child Psychol Psychiatry. 2011 April ; 52(4): 504–516. doi:10.1111/j.1469-7610.2010.02348.x.
  • Philip H Schwartz “The potential of stem cell therapies for neurological diseases”
  • Siniscalco D, Sapone A, Cirillo A, Giordano C, Maione S, Antonucci N. Autism spectrum disorders: is mesenchymal stem cell personalized therapy the future? J Biomed Biotechnol. 2012.
  • Careaga M, Van de Water J, Ashwood P(2010). Immune dysfunction in autism: a pathway to treatment. Neurotherapeutics. 2010 Jul;7(3):283-92.
  • Michael G. Chez* and Natalie Guido-Estrada (2010)Immune Therapy in Autism: Historical Experience and Future Directions with Immunomodulatory Therapy. Neurotherapeutics: The Journal of the American Society for Experimental NeuroTherapeutics.
  • Ghanizadeh A. c-Kit+ cells transplantation as a new treatment for autism, a novel hypothesis with important research and clinical implication. J Autism DevDisord. 2011 Nov;41(11):1591-2.
  • Ichim TE, Solano F, Glenn E, Morales F, Smith L, Zabrecky G, Riordan NH. Stem cell therapy for autism. J Transl Med. 2007 Jun 27;5:30.


2. HBOT or Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy (HBOT) is a medical treatment where in oxygen is delivered under pressure thus increasing the oxygen content in the blood and other affected areas. The whole process is conducted in a HBOT chamber, which may be frightening for some children with Autism. There is no evidence available currently to suggest that HBOT has any positive effects for children with Autism.

References:

  • “Hyperbaric oxygen therapy for treatment of children with autism: a systematic review of randomized trials”. Ahmad Ghanizadeh
  • Ghanizadeh Medical Gas Research 2012, 2:13 http://www.medicalgasresearch.com/content/2/1/13
  • “Using Behavior Analysis to Examine the Outcomes of Unproven Therapies: An Evaluation of Hyperbaric Oxygen Therapy for Children with Autism
”
  • Dorothea C. Lerman, Ph. D., TesaSansbury, Behavior Analysis in Practice, 1(2), 50-58.
  • “The effects of hyperbaric oxygen therapy on oxidative stress, inflammation, and symptoms in children with autism: an open-label pilot study
” Daniel A Rossignol, Lanier W Rossignol, S Jill James. BMC Pediatrics 2007, 7:36 doi:10.1186/1471-2431-7-36
  • Research article “Hyperbaric treatment for children with autism: a multicenter, randomized, double-blind, controlled trial
” Daniel A Rossignol, Lanier W Rossignol, Scott Smith. BMC Pediatrics 2009, 9:21 doi:10.1186/1471-2431-9-21


3. Yoga

Yoga's traditional knowledge concerns physiological and psychological processes that change physiological parameters through respiratory manipulation (breathing technique), postures (asanas), and cognitive controls (relaxation and meditation). Improvements in sensory integration, attention, sensory defensiveness, and increased verbal receptivity for commands related to spatial perception are reported in persons with Autism. A study done by Shanta Radhakrishna (Application of integrated yoga therapy to increase imitation skills in children with ASD- International Journal of Yoga, Jan-Jun, 2010), indicate that yoga can be an effective tool to increase imitation, cognitive skills and social-communicative behaviour in children with Autism. In addition, children exhibited increased skills in eye contact, sitting tolerance, non-verbal communication and receptive skills to verbal commands related to spatial relationship. (See for details:
http://www.ijoy.org.in/article.asp?issn=0973-6131;year=2010;volume=3;issue=1;spage=26;epage=30;aulast=Radhakrishna)
Since this is not an intervention with any side effects; we can recommend it. It is certainly not harmful.

References:

  • “Complementary and Alternative Medicine Treatments for Children with Autism Spectrum Disorders” Susan E. Levy, M.D. and Susan L. Hyman, M.D.
  • Child AdolescPsychiatrClin N Am. 2008 October; 17(4): 803–ix. doi:10.1016/j.chc.2008.06.004.


4. Dietary Therapy

There are some people who believe that Autism may be caused by the food that a child eats and from this belief have emerged the idea that restricting certain foods in a child with Autisms diet may help them. These diets may be highly exclusionary (that is may prevent the child from eating a normal balanced diet) or may target only one kid of specific food group (e.g., stopping wheat and or milk). Though some parents may report an ‘improvement’ in their child; these changes are rarely permanent and lack any evidence. A word of caution is that often these diets are very labour intensive and can potentially be expensive and difficult for a family. Another concern expressed by some families is that it further restricts socially appropriate behaviours e.g., grabbing biscuits from another child when they are not allowed at home, not being able to eat cake at a birthday party etc.

5. Dietary supplements

Because some people believe that their is something missing in the child with Autism’s diet they advise additional doses of these missing nutrients (e.g., Vitamin B6, Vitamin B12, Vitamin C, minerals such as iron, zinc or a mixture of such products).There is no evidence that these have any benefits and one must caution that some of these supplements may be dangerous if the child overdoses on them.

References:

  • Paul Whiteley1, Paul Shattock, Ann-Mari Knivsberg“Gluten- and casein-free dietary intervention for autism spectrum conditions”. Frontiers in Human Neuroscience www.frontiersin.org January 2013 | Volume 6 | Article 344 | 1
  • M. Mousain-Bosc, M. Roche, A. Polge. “Improvement of neurobehavioral disorders in children supplemented with magnesium-vitamin B6 II. Pervasive developmental disorder-autism” Magnesium Research 2006; 19 (1): 53-62 ORIGINAL ARTICLE
  • James B Adams, Tapan Audhya, Sharon McDonough-Means.
  • Adams et al “Effect of a vitamin/mineral supplement on children and adults with autism”BMC Pediatrics 2011, 11:111 http://www.biomedcentral.com/1471-2431/11/111
  • Susan E. Levy, M.D. and Susan L. Hyman, M.D.“Complementary and Alternative Medicine Treatments for Children with Autism Spectrum Disorders”
  • Child AdolescPsychiatrClin N Am. 2008 October ; 17(4): 803–ix. doi:10.1016/j.chc.2008.06.004.
  • Nye C, Brice A. Combined vitamin B6-magnesium treatment in autism spectrum disorder. Cochrane Database Syst Rev 2005:CD003497. [PubMed: 16235322]
  • Nye C, Brice A. Combined vitamin B6-magnesium treatment in autism spectrum disorder. Cochrane Database Syst Rev 2002:CD003497. [PubMed: 12519599]
  • Millward C, Ferriter M, Calver SJ, Connell-Jones GG
  • “Gluten- and casein-free diets for autistic spectrum disorder” (Review)
  • Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
  • Williams K, Marraffa C (2012). No evidence yet to support omega-3 fatty acids as a treatment for autism. J Paediatr Child Health. 2012 Jun; 48(6):534-6.
  • James S, Montgomery P, Williams K (2011). Omega-3 fatty acids supplementation for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011 Nov 9;(11).
  • Munasinghe SA, Oliff C, Finn J, Wray JA (2010). Digestive enzyme supplementation for autism spectrum disorders: a double-blind randomized controlled trial. J Autism DevDisord. 2010 Sep;40(9):1131-8.
  • http://autism.asu.edu/Docs/2013/Summary_of_Treatments_for_Autism-2013.pdf
  • Summary of dietary, nutritional and medical therapy 2013 version. Arizona State University Autism Research Program)
  • http://www.autismspeaks.org/news/news-item/ian-research-report-special-diets


6. Chelation therapy

Believers in the unproven theory that Autism may be caused by the accumulation of heavy metals, recommend this therapy where very toxic drugs are given to the child. These drugs may cause very severe adverse effects and this treatment is not recommended.

7. Probiotics or gastrointestinal medication

We all have millions of healthy bacteria in our intestine, which protects us from many infections. There is a belief that abnormal bacteria in the gut may result in the symptoms of Autism. Some proponents of this theory suggest giving supplements like yoghurt for children with Autism. There is no evidence to support this treatment, though most medications are harmless.

8. Music therapy

Currently, this is one of the most sought after and harmless treatment options for individuals with Autism. Supporters claim that the music has an effect on all the developmental domains especially improving communication and joint attention and possibly helping motor skills. There are a number of approaches some which are structured and others which are more improvisational.

9. Animal assisted therapy (AAT)

This involves a structured and supervised therapeutic interaction with animals (e.g. Horse riding, interactions with dogs etc), which are seen as transitional objects for initial bonding for individuals with ASD before generalizing this attachment to people. AAT appears safe (if done under trained supervision) sensible and possibly easy, though there is no evidence that this works to address the core symptoms of Autism.

Centre in India which offers AAT:

Dr. DOG – A Programme for children with Autism

See http://www.autismindia.com/article14.htm



10. Acupuncture

Acupuncture involves the systematic insertion and manipulation of thin needles into the body, to improve health of body/mind by unblocking the flow of “energy” and is a form of traditional Chinese medicine. For ASD, some evidence shows that this treated was tolerated by most patients with few or mild adverse-effects. Some outcomes for this therapy include improvement in attention, receptive language, self-care, language, overall functioning, and communication.

11. Exercise

In children with ASD, exercise may reduce hyperactive and repetitive behaviour through the release of certain chemical in the brain. This therapy seems sensible, cheap, safe, and easy and is therefore acceptable especially for those with repetitive behaviour.

12. Complementary and Alternative medicine (CAM)

Complementary and alternative medicine include a range of therapies that include mind-body therapies, manipulative and body based therapies ( including yoga), energy medicine ( including Pranik healing and acupuncture) or whole body treatments ( Homeopathy and Ayurveda). Although current data is insufficient to make clear suggestions as long as the therapy is not harmful or painful to the child with Autism a parent can be reassured that they are not hurting their child. However parents should be cautioned to utilise only those medication that come from reliable sources. For more on CAM: http:www.nccam.nih.gov

Making a decision

A parent may be confused by the choices being offered. Talking to other parents, developmental paediatricians and special educators may help you to make a decision. However, the website below can also help you make this decision though it is not directed at families of children with Autism.

http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/guidelines-for-using-complementary-and-alternative-methods

For a more you can explore the field of Autism Research the following site is very informative Click here: http://researchautism.net/pages/autism_treatments_therapies_interventions/

References:

  • Lofthouse, N. HendrenR , Hurt E, Arnold L. E., and Butter E ,A Review of Complementary and Alternative Treatments for Autism Spectrum Disorders Autism Research and Treatment Volume 2012, Article ID 870391
  • SrinivasanS.MandBhat A. N. A review of” music and movement”therapies for children with autism: embodied interventions for multisystem development, Frontiers in Integrative Neuroscience, April 2013, Volume 7, Article 22.
  • AccordinoR.,ComerR.,Heller W.B., Searching for music’s potential: A critical examination of research on music therapy with individuals with autism, Research in Autism Spectrum Disorders 1 (2007) 101–115.
  • Autism Research Institute. Treatment options for mercury/metal toxicity in autism and related developmental disabilities: consensus position paper. San Diego: Autism Research Institute, 2005.
  • Hardy W.M. and LaGasse B.A., Rhythm, movement, and autism: using rhythmic Rehabilitation research as a mode for autism; Frontiers in Integrative Neuroscience, March 2013 ,Volume 7 ,Article 19


Identifying the right intervention for yourself and your child:

Start intervention as soon as a diagnosis of Autism is received:

While early intervention started at a very young age is considered critical to the child’s learning, the reality is that every child with Autism can learn and progress with appropriate intervention. Regardless of the age at which diagnosis is received, intervention always gives positive results. Parents are therefore advised to start intervention as soon as a diagnosis of Autism is received.

Intervention plan will vary from child to child:

The way Autism affects each child is different, the intervention plan too will vary from child to child, as well as for the same child at different stages of his or her development.

Early intervention has to enable the child enjoy the process of learning:

Early intervention has to enable the child enjoy the process of learning. It has to address the main difficulties of Autism in the areas of social behaviour and communication. Some children with Autism use speech and some do not. Some children might have spoken as infants and then lost their speech. Many, who do speak, do not use their speech in a meaningful way.

Intervention should enable the child to lead an inclusive life:

Intervention should aim at helping an individual lead as ‘inclusive’ a life as possible. This means to be able to participate in activities which any other typically developing child of his or her age is able to. To achieve this, the main areas of impairment need to be addressed through specialized programmes developed over years of research, training and adaptation to the Indian context. Having said this, please stay away from those interventions that suggest that you are somehow responsible for your child’s Autism or that there is a ‘cure’.

Support programme should be based on the needs of the child and family:

Educational programme that provide educational support only in the area of academics may not be the best fit for most children. The nature of support should be based on the needs of the specific child. Clearly, teaching functional math skills may be more realistic for one child while another may be more than capable of complex higher skills.

Intervention programmes help enhance child’s independence:

An intervention programme aims to enhance the child’s independence and give more opportunity for personal choice and freedom in the community. To achieve this, it is vital to develop functional daily living skills at the earliest possible age. This could range from feeding and dressing oneself, to learning to cross a street safely, to making a simple purchase, asking for assistance when needed, or to simply responding with an “I don’t know,” when asked a question to which the individual with does not have the answer. These seemingly simple but critical skills may be difficult despite average intelligence levels.

Majority of them benefit from life skills instruction which might include learning purchasing and shopping, cooking, budgeting and banking, crossing the street and safety and first aid. These would also include the ‘soft skills’ of basic interpersonal relationships. For instance a student with less severe Autism, who receives good grades in computer science classes, but does not know how to engage in a social conversation in the school cafeteria needs life skill and social skill instruction.
 

 

 
 
  Autism Spectrum Disorders or ASD is commonly called Autism Neuro- typical: A term used for people who do not have Autism or ASD  
 
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