Chapter IV (continued) - Other Experiential Approaches

Other experiential approaches to intervention for young children with autism include a diverse collection of therapeutic models and approaches. Some of these approaches form the basis for intensive intervention programs while others are more limited in scope. Some of the approaches evaluated in this are commonly used; other approaches are less commonly used, and some are controversial. In general, there were few scientific studies found that met the criteria for adequate evidence about efficacy for the interventions reviewed in this.

The panel considered it important to evaluate these intervention approaches in the guideline because they are often used or discussed as possible interventions for children with autism. As with other parts of the guideline, the recommendations presented in this are intended to help professionals and families in making informed decisions about interventions for children with autism.


The Developmental, Individual Difference, Relationship (DIR) Model

The Developmental, Individual Difference, Relationship (DIR) model, which has been developed by Greenspan (Greenspan and Wieder, 1997) , is used as the basis for a comprehensive intervention approach emphasizing the child’s: (1) affect and relationships, (2) developmental level, and (3) individual differences (in motor, sensory, affective, cognitive, and language functioning). Intervention approaches using the DIR model are based on the theory that symptoms of a child with autism may be related to underlying biologically based processing difficulties which cause the child to have problems with relationships and affective interactions.

The intervention strategy based on the DIR model is sometimes informally referred to as "floor time" because the approach may include a component that encourages the therapist and parent to spend a great deal of time on the floor interacting with the child. At home, parents are asked to spend from six to ten daily sessions lasting 20-30 minutes working on the child’s ability for affective-based interactions using the child’s individual differences and developmental level as a starting point. Parents receive training and feedback on working with their child. Greenspan states that, "The floor time modelmobilizes the child’s emerging developmental capacities, and is based on the thesis that affective interaction can harness cognitive and emotional growth." (Greenspan and Wieder, 1997). Depending upon the child’s needs, the child may also receive other interventions, including behavioral and educational approaches.

Proponents of the DIR model consider it to be a conceptual framework that incorporates a variety of approaches tailored to the child's developmental level rather than a single, specific intervention method. In the panel’s opinion, some aspects of the DIR model may be consistent with the common elements of interventions that have been shown to be effective for children with autism in other programs and studies. The panel concluded that the DIR model forms the basis for some interventions currently being used for young children with autism and, therefore, the panel chose to evaluate the DIR model as a general intervention method.

Interventions Based on the Developmental, Individual Difference, Relationship (DIR) Model

Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

Recommendations

  1. It is important to recognize that there is no research evidence that intervention approaches based on the Developmental, Individual Difference, (DIR) model are effective as intervention for young children with autism. However, some aspects of the DIR model may be consistent with desirable elements commonly used in other intervention approaches, such as

  • the importance of child-specific assessment
  • individualizing the intervention to the child's strengths and needs
  • involving the family in the intervention [D1]

  1. Without evidence from controlled studies using generally accepted scientific methodology that demonstrates effectiveness, interventions based on the DIR model cannot be recommended as primary interventions for young children with autism. [D1]
  2. It is important to recognize that approaches based on the DIR model can be time-intensive for both professionals and parents and may take time away from other therapies that have been demonstrated to be effective. [D1]
  3. If interventions based on the DIR model are being considered for a young child with autism, it is essential that the interventions based on the DIR model:

  • set defined treatment goals and objective outcome measures
  • define treatment goals appropriate for the individual child
  • provide for baseline and ongoing assessment of the child's progress
  • provide for appropriate modification of the treatment plan based on the child's progress, including consideration of other interventions if the child is not improving
  • be coordinated with any other interventions the child may be receiving to avoid any potential conflicts in establishing and achieving goals for the interventions [D1]

  1. If interventions based on the DIR model are being considered for young children with autism, it is important that parents and professionals together make an informed decision on whether to try DIR-model interventions based on the following information:

  • there is no adequate research evidence that interventions based on the DIR model are effective for treating autism in young children
  • interventions based on the DIR model may interfere with an intensive behavioral/educational program unless steps are taken to coordinate the two interventions
  • although interventions based on the DIR model are not likely to be physically harmful, they are time-intensive and may take time away from interventions that have been shown to be effective [D1]

Sensory Integration Therapy

Sensory integration therapy is based on the theory that in a normal individual the brain integrates various sensory messages in order to form coherent information on which the person can act. These sensory messages may include sight, hearing, smell, taste, touch, sense of position, and others. This theory also maintains that the process of normal sensory integration may be absent or malfunctioning in some individuals, especially in persons with autism. The stated goal of sensory integration therapy is to facilitate the development of the nervous system’s ability to process sensory input in a more normal way (King, 1987).

Sensory integration therapy is based on an approach that evaluates children for sensory processing disturbances and provides them with the appropriate sensory stimulation. The techniques used to provide the sensory stimulation are individualized based on evaluating the child’s responsiveness to specific forms of sensory stimuli (visual, auditory, tactile, vestibular, proprioceptive, olfactory, and gustatory stimuli). Sensory experiences involving touch, controlled movement, balance, or passive sensory input are then provided to the child to elicit adaptive responses to these stimuli. The sensory experiences used generally include goal oriented play using activities that offer opportunities for enhanced sensory intake.

Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

Recommendations

  1. It is important to recognize that there is no research evidence that intervention approaches using sensory integration therapy are effective as an intervention for young children with autism. [D1]
  2. Without evidence from controlled studies using generally accepted scientific methodology that demonstrates effectiveness, sensory integration therapy cannot be recommended as a primary intervention for young children with autism. [D1]
  3. If sensory integration therapy is being considered for a young child with autism, it is essential that the sensory integration therapy be coordinated with other interventions the child is receiving to avoid any potential conflicts in establishing and achieving goals for the interventions. [D1]
  4. If sensory integration therapy is being considered for a young child with autism, it is important that parents and professionals together make an informed decision on whether to try sensory integration based on the following information:

  • there is no adequate research evidence that sensory integration is effective for treating autism in young children
  • sensory integration therapy is not likely to be physically harmful, and there may be some benefits from the physical activity involved with sensory integration [D1]

  1. If sensory integration therapy is being considered as an intervention for a young child with autism, it is important that a treatment plan for sensory integration be developed and that the treatment plan:

  • be compatible with the approach and goals of the primary intervention
  • set defined treatment goals and objective outcome measures for the sensory integration therapy
  • define treatment goals appropriate for the individual child (such as reduction in the child's stereotyped behaviors or aversion to touch)
  • provide for baseline and ongoing assessment of the target behaviors
  • provide for appropriate modification of the sensory integration therapy based on the child's progress [D1]

Auditory Integration Training (AIT)

Auditory integration training involves doing an audiogram to test the child's hearing. Based on audiogram results, music played through headphones is modified by filtering those frequencies that the child hears the best.

The evidence reviewed included a randomized controlled trial that found no differences in children receiving auditory integration training as compared with those listening to the same music which had not been modified. Several children in both groups experienced transient sleep disturbance during the intervention, and some instances of ear, head, and stomachaches were reported.

Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

Recommendations

  1. Because of the lack of demonstrated efficacy and the expense of the intervention, it is recommended that auditory integration training not be used as an intervention for young children with autism. [C]

Facilitated Communication

Facilitated communication involves a "facilitator" who supports the child's hand on a keyboard or letter board while the child types or spells messages. Proponents of this therapy suggest that the messages are communications coming from the child.

In studies of facilitated communication used in older children with autism, the messages typed by the children are often far beyond their capabilities as evidenced by their behavior or language. Studies of facilitated communication suggest that communication that exceeds baseline levels for a subject originates from the facilitator rather than the child.

Use of facilitated communication has brought up a number of ethical and legal issues. There have been cases where messages produced with facilitated communication have caused emotional distress to parents or have led to accusations of abuse that resulted in legal proceedings.

Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

Recommendations

  1. Because of the lack of evidence for efficacy and possible harms of using facilitated communication, it is strongly recommended that facilitated communication not be used as an intervention method in young children with autism. [D1]

Music Therapy

While music activities are often included within the context of many intervention approaches for children with autism, there are also some who advocate for a separate, discrete intervention approach referred to as "music therapy". For children with autism, music therapy (as a separate discrete therapy) involves using some aspect of music, although the particular procedures used in music therapy vary and were not well defined in the literature reviewed. Proponents of music therapy (as a separate discrete therapy) suggest it may lead to improvements in social interaction and language development in children with autism.

Music therapy has not been demonstrated to have efficacy in a controlled study using generally accepted scientific methodology. Because of the lack of demonstrated efficacy, music therapy cannot be recommended as an intervention method for young children with autism.

Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

Recommendations

  1. Music therapy is not a recommended intervention method for young children with autism. [D1]
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Touch Therapy

Touch therapy is a particular method of massage that involves specific sequences of rubbing the body using moderate pressure and smooth stroking movements. It is performed on individuals who are fully clothed except for their socks and shoes. Areas of the bodies rubbed may include the head, neck, arms, hands, torso, legs, and feet. Proponents of touch therapy suggest it may be beneficial for children with autism who often have problems with touch aversion, withdrawal, and inattentiveness.

There is insufficient evidence to make a recommendation in favor of touch therapy as an effective intervention for young children with autism. Further research would be needed to replicate the effects of the one study that met criteria for evidence in order to make a recommendation for the use of this intervention approach in young children with autism.

Evidence Ratings: [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/No evidence meeting criteria [D2] = Literature not reviewed

Recommendations

  1. Touch therapy is not a recommended intervention method for young children with autism. [C]

Medication and Diet Therapies