Clinical: Managing Autism in Children

No other psychiatric diagnosis has more profound negative implications than autism. On the surface, autism impacts social, emotional, behavioral, and academic functioning. However, autism is pervasive in ways less immediately observable, and, as a result, children with autism require developmental and educational interventions that are different in both form and intensity from those required by children with other special needs.

Finding the appropriate intervention is difficult. A parent must first have an in-depth understanding of the diagnosis because, to be of benefit, interventions need to be geared to the individual child. Assessing general intellectual and developmental functioning and the presence of comorbid disorders is a first step in identifying appropriate interventions. This is best accomplished by a multidisciplinary approach, and guidance and coordination by the psychiatrist is crucial.

Psychiatrists must also address the parents' functioning and adjustment to the diagnosis: prolonged reactions of shock, denial, helplessness, guilt, anger, grief, and resentment interfere with the parents' ability to negotiate the many obstacles they will face in securing effective services for their child, not just initially, but over the course of their child's life. Parents will find that the most sought-after and proven programs (such as those that primarily use the principals of applied behavioral analysis [ABA]) are limited in availability because of funding issues, waiting lists, or geography. Adding to the stress is that time is of great importance; there is substantial evidence that early and appropriate intervention is strongly related to better outcome.

For psychiatrists to advocate for these children, it is necessary to become familiar with why these children need specific and intensive ser- vices, how these interventions are applied, and what the outcomes are of these treatments.

How are children with autism different?
Children with autism have fundamental and pervasive differences in their readiness and ability to learn. While the nonautistic, developmentally delayed child will need special assistance to learn, the autistic child must first "learn to learn." Most intellectually impaired children have a consistent learning trajectory. They may learn more slowly, and their ultimate level of achievement may be less than average, but they possess an innate ability and interest to attend to their surroundings in a manner that sets the stage for learning to occur. Disorders such as depression or anxiety in children may interfere with optimal learning and functioning, but children with depression or anxiety disorders are not pervasively compromised in the fundamental skills. Children with autism lack such fundamental skills, and the consequent learning disabilities can be numerous (Table 1).

Limited sustained attention in children with autism consistently and negatively impacts not only their pace and persistence with tasks (a primary limitation) but also their basic ability to benefit from exposure and experience. Children with autism may engage in stimulus selectivity by focusing on a particular object or stimulus to the exclusion of others. Verbal stimuli, the source of most learning experiences at home and in school, are often of little interest. Children with autism are often distractible because they are easily overwhelmed by external and internal stimulation, which they cannot decipher or modulate. The ring of a telephone may set off reactions ranging from overactivity (responding to everything) to withdrawal (tuning out and avoidance). Their inability to prioritize relevant stimuli is another deficit.

Autistic children are poor respond- ers to external or internal rewards. They have little self-awareness and, therefore, do not experience the natural pride that comes with success. Autism also interferes with a child's sense of the bigger picture—understanding why learning is important. With circumscribed interests, even rewards that are commonly sought out by other children (eg, toys, praise) are initially of little value to children with autism.

Many children with autism must be taught to do what comes naturally to their more typical peers, namely initiate meaningful, planned, and playful interactions with their surroundings. For most children, the joy of play-related learning comes from 2 sources: the pleasure of engaging in the behavior and the result of their accomplishments. They learn to generalize their play experiences to the broader world. Play also encompasses imitation, another skill deficit in children with autism, who have to be taught to attend to and mirror others.

As a result of neurobiological development and the benefit of instruction, over time, most children mature into abstract thinkers. Abstract thinking in young children does not equate with the ability to sort out complex motivations. Instead, one aspect of abstract thinking translates into seeing an action as a means to an end. Children with autism generally do not have this understanding, and their motivation for learning a behavior is limited. In addition, children with autism are limited in their ability to enjoy and benefit from representational play. They are unable to recognize that a toy, picture, or symbol is a representation of something in real life that can be used for learning and and something that they can engage in.

Mental retardation and anxiety disorders are the most common comorbidities with autism, although attentional and communication deficits are of significant concern as well. Even mild general cognitive delays hamper the limited learning abilities of many children with autism. Symptoms of anxiety may be partially related to the specific neurobiological makeup of these children, but whatever the cause, avoidance of novel situations and insistence on routines are clearly related to anxiety. Emotional dysregulation and deficits in receptive and expressive language may result in anxiety and frustration. Tantrums and/or aggressive behaviors are also obstacles to learning.

What is applied behavioral analysis?
ABA is not a specific technique or treatment. Rather, it is an approach to learning that focuses on the acquisition of skills to enhance attention, communication, imitation, play, activities of daily living, and socialization. The principles of ABA have been used to enhance competence, functioning, and prosocial behavior in a wide variety of populations and contexts, and this same approach has been used to address the symptoms of autism. Although programs for children with autism that use the science of ABA are casually referred to as "ABA programs," this term does not describe a specific program.

ABA is an ordered, sequenced approach to learning that can be measured and quantified. The broad goal is to maximize the child's behavioral repertoire and solidify his or her ability to learn from instruction and experience. ABA techniques can address each of the skill deficits that interfere with the developmental trajectory of an autistic child. Unlike the typical school environment (although some programs are in public schools), programs for children with autism, especially those with a behavioral focus, recognize that the visual and physical environment of even a special classroom may be too chaotic for a child with autism, resulting in maladaptive behaviors and routines that are damaging to learning and difficult to extinguish.

While other programs also incorporate approaches to behavioral change, ABA is characterized by techniques that are focused on the acquisition of skills and that create a successful learning environment. The approach is geared to the individual child through a careful, ongoing, and objectively measured assessment of the child's abilities, needs, interests, and progress. As noted in a 1999 report on mental health by the Surgeon General, David Satcher, "Thirty years of research has demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior."

Programs for children with autism that use ABA are based on a carefully crafted instructional plan, and it is assumed that parents will contribute to its development with their observations and opinions. Many comprehensive and readily understandable guides to program development are available to parents, teachers, and clinical interventionists, although even the most motivated parent or teacher needs intensive training to successfully implement behavioral treatment.

Table 2 presents sample questions that should be considered in instructional planning.

Discrete trial training: the heart of the ABA approach

Discrete trial training (DTT) is a unit of instruction that is generally implemented one-on-one in a distraction-free setting. It uses behavioral terminology to describe instruction but translates it to easily understandable terms. DTT uses “discriminative stimulus,” simply the instruction, “Stack, please!” followed by a response (the child stacking, not stacking, or doing something else), and the consequence or reinforcing stimulus (usually a reward if correct) or a response by the instructor that the child’s response is incorrect (silence, “Nope!,” prompting, or other direction by the instructor). The child’s response should occur in 3 to 5 seconds and should consist of the “target” behavior.

There have been questions about the use of DTT in autism intervention. The most common concerns focus on potential lack of generalization, cue dependence, and lack of creativity. However, these concerns may be misleading for parents and are not supported by outcome data when there is appropriate program development. It is generally a misnomer to bifurcate learning in a “naturalistic” manner versus DTT. Most comprehensive ABA programs use DTT for initial skill acquisition and to broaden the child’s experiences (at home, in school, and in the community) for generalization. These programs also incorporate many techniques that promote skill independence and avoid what has been inappropriately coined as the “robotic” outcome of ABA.

Issues have been raised regarding the affect of instructors. While parents obviously need to carefully research the competencies and training of all instructors (especially in home-based programs), ABA instruction (at least initially) is not the same as classroom teaching. Because of the unique functioning of these children and the demands of ABA, instructors must be clear and direct in their directions and consistent in their responses. This does not mean that ABA instructors are unloving or unkind. Just the opposite, their primary goal is to provide reinforcement for the child and to be mutually connected. Anyone observing a solid ABA-type program in action can immediately see the teacher’s care and concern for the child and the child’s developing positive response to success.

Questions have been raised regarding “aversives” for behavioral management of unwanted behaviors. ABA provides proven methods for discouraging unwanted behaviors, and the use of negative or aversive consequences is a natural part of instruction. Mild negative experiences, such as a “Nope!” or removal of a toy, although seemingly harsh, can be an effective tool for the enhancement of functional behaviors and the extinction of unwanted behaviors.

Some specific applications

Many behavioral techniques are available to enhance learning and functioning. These are used to build behavioral repertoires and meaningful adaptive behaviors.


 * Prompting is assistance given to promote correct responding. All of us respond to prompts. Prompts should be as unintrusive as possible, and may be verbal or physical, such as “hand-on-hand” direction, pointing, tapping, or glancing.


 * Fading is used to prevent the child’s dependence on prompts and reinforce independent behavior. Prompts may be used intermittently and correct responses “overlearned” so that prompts become unnecessary.


 * Chaining is the creation of a complex behavior by combining simple behaviors into a sequence. Teachers use task analysis to break down a desired behavior into smaller components or steps, assisting the child in mastering these pieces, then reinforcing parts of the chain and then the whole. For example, removing the top from a water bottle may involve holding the bottle, touching the top, moving the top to open it, and placing the top on the table. Such a skill may take days to months to learn.


 * Shaping is gradually modifying an existing behavior into a target behavior by reinforcing successive approximations of the target behavior.


 * The use of extended trials builds memory of a newly acquired behavior. The child must demonstrate response to a command and discriminate this from distracters. For example, a child who learns “clap hands” to a specific accuracy will then be asked to “clap hands” interspersed with other known commands, such as “touch nose.”

Treatment effectiveness
ABA and related structured educational interventions have been shown to be effective for many children with autism and may have a better outcome than other interventions. However, treatment effectiveness is based on many factors, some general and some more specific; thus, careful and comprehensive assessment is key in making informed decisions about program choice. ABA has many years of documented success for autism intervention. Interventions are most effective when they are implemented for many hours a day and/or in a variety of environments that are common to the child’s daily experiences, and intensity is usually related to the best outcome.

Early intervention is key. Certain developmental skills must be learned during critical periods of neural maturation and before the development of interfering behaviors and prolonged parental grieving. The implementation of educational interventions in specific ABA-type programs is significantly more effective in terms of long-term outcome when treatment begins as early as possible. Thus, parental support for follow-through, psychiatrist advocacy, and prompt referral for diagnosis is crucial. ABA has demonstrated effectiveness with older children (aged 5 years and older), but the advances may be limited. However, this is not a reason to suggest that ABA should not be the treatment of choice for many children with autism, regardless of age at initial treatment.

All programs require parental support to varying degrees. Although some ABA programs are “in-home” (usually by parental choice) all parents need to familiarize themselves with treatment principles and work toward generalizing and reinforcing behaviors and skills at home.

Related and adjunct interventions

Programs that incorporate principles of behavior analysis among other approaches have also shown promise. Some of these programs are “naturalistic” and incorporate discrete trial behavioral intervention with more natural or child-initiated interventions. These naturalistic programs may promote greater generalization of behaviors and greater positive child and parental affect. The best known school-based educational program is treatment and education of autistic and communication handicapped children (TEACCH). This, and similar programs, use “structured teaching” and create a learning environment to fit the “culture of autism.” TEACCH classrooms organize the physical environment; develop schedules and work systems; make clear expectations; use primarily visual cues; and reduce dependence on prompting, encouraging self-maintenance and goal-directed behavior. “Floor time” is a developmental approach that focuses on building emotional reciprocity, and, while following the child’s lead, shapes behavior and communication.

Unfortunately, program outcome measurement has been difficult to replicate using independent investigators, although many of these programs have had considerable parental and legislative support. As in any case, outcome depends on abilities assessed, and “success” in one program may be different from “success” as measured in others. Parents and advocates need to carefully assess the goals and techniques of any intervention, and weigh these against documented outcome criteria and the specific characteristics of a given child.

Adjunct interventions are also important. Medications can set the stage for greater treatment responsiveness and adjustment to home and programming. When cooperative, attentional, and social skills improve, children may be ready for more intensive speech and communication therapy, which can include a wide range of goals, from the use of sign language and picture communication to higher levels of verbal interactions. Various additional auxiliary resources may add to the functional abilities of the child.

The psychiatrist’s role

If anyone ever needed advocacy, it is the parents of an autistic child. Although theoretically every autistic child is guaranteed the right to an appropriate education, in practice it is not an easy path from diagnosis to service provision. In addition to providing emotional support and solid treatment for the child, the psychiatrist can use the strategies presented in Table 3 for managing children with autism and in addressing parental concerns.

The psychiatrist need not be a legal or educational expert but should be knowledgeable enough to know when to advise the parents to ask questions or to take a stand. A friendly acquaintance who is a specialist in educational advocacy is also beneficial. No child should be placed in a program because it is good for the school or pocketbook.

Child psychiatrists are in a unique position to provide support and education to parents of children with autism. Parents are faced not only with this potentially devastating diagnosis but also very real frustrations in finding treatment and in identifying specific behavioral and educational interventions. Being able to explain why children with autism need special interventions will go far in helping parents knowledgeably advocate for their child. Likewise, the psychiatrist can be a more effective advocate and treatment coordinator with a basic understanding of the unique and pervasive deficits that present in autism. Finally, the psychiatrist must be able to communicate why early and intensive programming is a clinically and scientifically sound practice.

Dr Brams is a clinical psychologist in Columbus, Ohio, and the director of a clinical practice and a forensic psychology consulting firm. She is the author of How to Do Your Best on Every Test and coauthor of other educational psychology books. She is an adjunct faculty member at The Ohio State University. She reports no conflicts of interest concerning the subject matter of this article.

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Koegel RL, Koegel LK, McNerney EK, et al. Pivotal areas in intervention for autism. J Clin Child Psychol. 2001; 30:19-32.