Behavioral modification approaches to treating autism communication disorders

Autism is one of the most severe and disruptive of all childhood disorders - a level of disruption that of course lasts well into adulthood. With both genetic and environmental elements at work, autism (which affects boys at least three times more often than girls and is found in all races and throughout the world) is a communicative disorder that interferes with an individual's ability to form social relationships as well as to communicate with others.

The inability to communicate easily with others is devastating for many children with autism. Being disconnected from other members of the human community is always a difficult condition, but it is especially difficult to the young. An adult who finds himself or herself unable to communicate will already have established connections with other people.

But a child with autism often has the greatest possible difficulties communicating and so establishing those connections to begin with. It is often difficult for the child with autism to have a complete understanding not only of individual human relationships but of human society as a whole.

Behavioral modification models of treating autism, such as those that are discussed in this paper, provide a way of easing the communication barriers between those with autism and other people, thus allowing autistic children to build the kind of initial human connections when they are young that they will be able to build on later in life.

Although we have all heard of autism, we may not be entirely clear what the syndrome consists of, which is not surprising given the range of symptoms that different individuals manifest.

In general, those who suffer from autism exhibit a number of behaviors distinguished by dramatic and sometimes even violent symptoms. These behaviors are often so marked that prevent autistic children cannot be educated in traditional classrooms, which tends to further limit their chances to develop good communication skills. However, they can often be helped with a combination of special education classes and private therapy.

However, while it is true that special-education classrooms are often the best educational arena for autistic children, the autistic individual's behavior may make it difficult for him or her to be educated in any classroom and so to use the chances usually afforded by the classroom to learn communication skills.

Autistic behavior is primarily marked by significant, almost violent withdrawal from the social world and an extreme (again almost violent at times) aversion to entering the what be called the "social spaces" of others - generally that physical distance between people within which it is comfortable to hold a conversation. (This might also be seen as the range of easy human communication.)

Autism is also generally marked by a range of behaviors that may appear bizarre and quite frightening to those who are not familiar with the syndrome. These too limit the chances that an autistic child has to learn appropriate and effective communication skills.

Unfortunately, the communication problems that autistic children themselves have may be exacerbated in the special-education classrooms that they tend to be schooled in and in which other children do not themselves have sufficiently well-developed social skills to recognize the needs of the autistic child.

Paluszny (1979) bluntly summarizes autism as being characterized by "a lack of social relationship, a lack of communication abilities, persistent compulsive rituals, and resistance to change" (p. 1). These same attributes that make a sheltered learning environment necessary for the autistic child also tend to interfere with the practice that autistic children - more than most - need in acquiring and practicing communication.

In general, autistic children will not learn to communicate with others unless they undergo special training and therapy. Behavior modification models are generally considered to be the most effective against autism. This citation summarizes the effectiveness of behavioral modification in helping autistic children to acquire communication skills:

The Lovaas research did not evaluate the effectiveness of his behavior modification therapy against other intervention strategies. The comparison intervention used with the control group was the same type of behavior therapy, but less intensive (10 hours or less per week compared to 40 hours or more). Thus, it is possible that the intensity of the intervention was more important than the specific strategies used or behaviors targeted. In terms of short-term impact, there is some evidence that a "natural language paradigm (NLP)" as implemented by the Koegels and their colleagues may be more effective in enhancing language acquisition and interaction in children with autism than a more traditional behavior modification approach as described by Lovaas (1981). The NLP involves (1) use of functional stimulus items chosen by the child; (2) natural reinforcers; (3) reinforcement of communicative attempts even if they are not "correct;" and (4) intervention trials interwoven within a natural exchange. The long-term impact of intensive and early exposure to the NLP has not been evaluated, however. A recent book edited by Koegel and Koegel (1995) describes the NLP and provides an excellent update on the advances in programs for children with autism which have been developed within a behaviorist framework (http://www.unc.edu/~cory/autism-info/cshaart.html).

What Causes Autism?

One of the maddening aspects in terms of the treatment of autism is that researchers do not know exactly what causes it, ensuring that it is all that much more difficult to treat. The etiology - or underlying cause - of autism has remained difficult for researchers to determine precisely and is a subject beyond the scope of this paper. (In other words, researchers have some basic idea about its cause but do not know the details).

This discussion focuses on intervention therapies for the autistic child who is having problems speaking with and listening to others - and specifically on those forms of therapy based in behavioral analysis or assessment that have been successfully used for autistic children - but this does not mean that we can afford to ignore the biology of autism entirely.

Autism is not caused by inappropriate parenting or other psychosocial variables in the home life of the developing child.

The specific underlying psychological or neuro-physiological mechanisms are simply not known. Although a number of different theories have been put forward, none has withstood closer scrutiny. Probably several causes and etiological pathways lead to disorders in the autism spectrum. There is no reason to suppose there is only one pathway. The search must continue (http://www.behavior.org/autism/index.cfm?page=http%3A//www.behavior.org/autism/autism_causes.cfm).

This should not be construed to mean that questions of etiology are not important: The cause of autism remains an obviously worthy subject of future research. However, until the etiology of the syndrome has been determined in a way that allows for it to be treated in a medicalized manner, practical therapeutic treatment options must be of at least equally compelling if not more compelling concern.

In other words, because the mechanism that causes autism has not yet been identified, it cannot now be treated. As is the case with other diseases and conditions whose cause is not know, the symptoms themselves must be treated.

While this is not in some ways as effective as treating the root cause, addressing the symptoms of autism can itself be quite effective.

Both because the etiology of the syndrome is little understood and because raising children with autism is an extremely frustrating task, the syndrome has generated a number of treatment possibilities. One might in fact argue that a great deal of the variety in the treatment options now being advocated and tried has arisen from the almost desperate (but entirely understandable) desire on the part of parents, teachers, and health-care professionals to treat autistic children in any possible way.

Without any clear pathway to take to treat such a disabilitating conditions, in other words, people are willing to try a lot of different strategies.

However, it is also true that the diversity of treatment options that exists today to address the communication problems of autism may stem primarily from the fact that autism is a remarkably heterogeneous phenomenon. In other words, individuals who have autism manifest such a wide diversity of behaviors that no one treatment plan may be able to be effective with everyone with autism.

Of course, any treatment plan has to be sensitive to the specific needs of specific individuals. Nonetheless, some basic and generalizable principles for treatment exist that can be applied to all individuals with autism regardless of age or severity. Among these general principles is the model of behavior assessment.

Behavioral analysis - which is also sometimes called behavioral assessment - has in the past decade proven to be by far one of the most promising treatment methods for autistic individuals. Not only is it proving to be more effective but it is also arguably far more humane than earlier methods, which consisted almost entirely of institutionalizing children with this syndrome, removing them from their families and costing them any chance of normal communication with the rest of the human family.

Functional behavioral assessment means the process of determining why a student engages in behaviors that impede learning and how the student's behavior relates to the environment. The functional behavioral assessment includes, but is not limited to, the identification of the problem behavior, the definition of the behavior in concrete terms, the identification of the contextual factors that contribute to the behavior (including cognitive and affective factors) and the formulation of a hypothesis regarding the general conditions under which a behavior usually occurs and probable consequences that serve to maintain it (http://www.vesid.nysed.gov/specialed/publications/policy/evalsappa.htm).

It should be noted that while behavioral assessment may help provide a substantial amount of help to many individuals suffering with autism it is certainly not a cure-all (Smith, Chung, and Vostanis, 1994, p. 558). However, it can be used to help improve the communication of many children with autism because it is a highly flexible model that can be used by parents, teachers, therapists and others to help autistic children acquire communication skills no matter what level they may be at in terms of development or severity of symptoms.

Assumptions of behavioral analysis

Behavioral analysis, which is also referred to as behavioral assessment, takes as an initial starting point the idea that the problem in a behavior (such as the behaviors evidence by autistic children) lies in the behavior itself rather than in the individual.

Functional behavioral assessment is generally considered to be a problem-solving process for addressing student problem behavior. It relies on a variety of techniques and strategies to identify the purposes of specific behavior and to help IEP teams select interventions to directly address the problem behavior. Functional behavioral assessment should be integrated, as appropriate, throughout the process of developing, reviewing, and, if necessary, revising a student's IEP.

A functional behavioral assessment looks beyond the behavior itself. The focus when conducting a functional behavioral assessment is on identifying significant, pupil-specific social, affective, cognitive, and/or environmental factors associated with the occurrence (and non-occurrence) of specific behaviors. This broader perspective offers a better understanding of the function or purpose behind student behavior. Behavioral intervention plans based on an understanding of "why" a student misbehaves are extremely useful in addressing a wide range of problem behaviors (http://cecp.air.org/fba/default.htm).

If we take this as our beginning point, the logical next step is that it is the environment that triggers behaviors in autistic individuals that must be modified and not the individual.

Two parents who have autistic children were interviewed to see if they agree with this model of treating children with autism. They both found it extremely useful in helping their children development communication skills:

really never thought that we would be able to have my son in a school setting at all. The first four schools that we were in - there was always very much this attitude that it was the child's fault, that we had to modify his behavior as the starting point.

But he just wasn't really at the point where he could do that yet.

But with this teacher, the teacher created a corner of the room in which the environment was controlled in a way that the children could handle it. The level of stimulation was kept very low, and the teacher worked very hard with the other students to get them to respect this space.

If the autistic children came out of their area, then the other kids were to treat them "normally," but within their area there was a different set of rules.

This parent of another child with significant autistic symptoms agreed:

We really thought that we had tried everything, including a lot of behavioral modification. And I think that maybe that will work when he is older - or maybe in conjunction with other models and therapies.

But when he was just beginning school, the pure behavior modification programs didn't work with his level of social skills and especially communication.

This is a form of behavioral modification, of course, which is why it works. But the locus is different - I guess you could say that the sense of blame or responsibility is shifted so that the child isn't at fault. That makes all the difference.

Autism is a complex and often frightening syndrome that interrupts life in very early childhood at precisely the same developmental age that most children are becoming intimately connected to the social world of humanity through various forms of communication. Behavioral assessment provides a method for restoring those connections.