Early Intervention in Autism

Summary of Dawson & Osterling review, and comparison to Harris & Handleman review

Early Intervention in Autism
Summary of Dawson & Osterling review,
and comparison to Harris & Handleman review
Lisa Simmermon, 02/2000

Dawson, G., Osterling, J. (1997). Early Intervention in Autism, in M.J. Guralnick (Ed.), The Effectiveness of Early Intervention (pp.307-326). Kansas City: Paul H. Brooks Publishing Co., Inc.

Key Points

autism can be identified in very young children by:
A) difficulties in:
1. orienting to social stimuli,
2. impoverished social gaze
B) impairments in:
1. areas of shared attention
2. motor imitation
prevalence (1996 information)
autism 5:10,000
PDD’s (other than Autistic disorder) 15:10,000
(3 x autism prevalence – this is significant for intervention program development)
eight effective autism early intervention programs are reviewed
– 5/8 are ABA based (Douglass Developmental Disabilities Center at Rutgers University, Learning Experiences…An Alternative Program for Preschoolers and Parents , May Institute in Boston, Princeton Child Development Institute at Princeton University, Young Autism Program at the University of California at Los Angeles), 1/8 uses structured teaching (Treatment and Education of Autistic and Communication-Handicapped Children at the University of North Carolina at Chapel Hill), 2/8 use play/incidental teaching (Health Sciences Center at the University of Colorado, Walden Preschool at the Emory University School of Medicine),
– average age of entry 3.5 – 4 years
– 3 year duration, except in Young Autism Program which is 4 years
– minimum hrs/week school-based intervention (7/8 provided at least hrs/wk of school-based intervention, and 1/8 provided 15 hrs/wk; the range was 15 to 40 hrs/wk; average was 27 hrs/wk of school-based intervention)
– 4/8 have in-home elements (home/family training, home visits/support) (3/4 are ABA based, 1/4 is play based) (home programming time was not specified, but was probably in the range of 2 – 4 hrs/day 14 to 28 hrs/wk, with a probable average of 21 hrs/wk, which would bring centre & home based programs total programming hours to a probable average of 27 + 21 48 hrs/wk)
– all have parent training and parent support
– 6/8 involve some inclusion/integration of typically developing peers, 6/8 start non-integrated, 4/8 progress from non integrated to some integration
outcome data: 150 children over 8 programs
– success in fostering positive school placements
– significant developmental gains
– 4/8: 50% integrated into general classrooms by end of early intervention
– IQ gain averaging approximately points (significant since starting IQ was usually below 70)
– 50% made very significant gains, about 45% made significant gains
– the ABA programs report that positive effects are maintained through elementary school years (only the Lovaas ABA early intervention studies included control groups, so gains experienced by the children with autism can be attributed to his ABA early intervention)
children with autism are most often not capable of gaining skills in more complex environments that typically involve small or large groups of children
with autism have such severe information-processing impairments that they have difficulty attending to and encoding critical information such as gestures, language and facial expressions.
children with autism often show large discrepancies between their performance levels in highly supportive versus more natural, complex environments
motor imitation is a fundamental mechanism for learning, and most children with autism fail to spontaneously imitate the motor actions of others (Curcio, 1978; Dawson & Adams, 1984) (this is significant to support the need for Occupational and/or Physical Therapy)
children with autism often have significant visual and auditory memory limitations
children with autism need to use specific prompts and familiar cues learned in a high-support environment (optimal performance level) to develop long-term memory encoding enabling spontaneous regeneration of the new skill with reduced context support (functional performance level)
key symptom of autism is a strict adherence to specific routines and a need for sameness in the environment
children with autism become more socially responsive and attentive when information is provided in a highly predictable manner, and, conversely, that their behavior is severely disrupted when the same stimuli are presented in an unpredictable manner
children with autism have difficulty in the classroom with transition from one activity to another and with any unanticipated change from expectations
children with autism have a need for predictability and routine, which may be due to:
1) difficulties in arousal modulation,
2) impairments in memory
3) impairments in processing of temporal information
programs must facilitate successful transition from preschool to kindergarten or first grade due to the challenge children with autism have making changes and generalizing previously acquired skills to new environments
Common Elements of Effective Autism Early Intervention Programs

Regular administration of standardized assessments
– all: communication, autistic symptoms, adaptive behaviors, IQ
– some: play, motor and social skills
Autism specific curriculum content
1) ability to attend to elements of the environment that are essential to learning (pay attention, especially to other people; respond to social stimuli ; shift attention; attending to multiple stimuli; sharing attention states with others)
2) ability to imitate others, develop representational thought & social skills, and provide a context of mutuality in which communication and empathy may develop)
a) verbal
b) motor
3) ability to comprehend and use language
a) recognizing motivational issues and increase motivation with positive reinforcement
b) develop concept of communicative intent
c) provide exposure to a range of communication modalities
(visual symbols, gestures, written words, speech)
4) ability to play appropriately with toys
a) increase ability to use toys in functionally appropriate ways
b) promote the use of symbolic play (through physical and verbal prompts)
5) ability to socially interact with others (especially with peers)
a) specific skill instruction (turn taking, sharing I) with adults, II) with children)
b) facilitate skill development by including NT peers (NT neuro-typical typically developing)
Provision of highly supportive teaching environments and generalization strategies:
develop core skills (skill domains that are inherently part of the autistic syndrome and are critical for the acquisition of knowledge: attention, compliance, imitation, communication, appropriate toy play & social skills)
1) establish core skills in highly supportive teaching environments providing:
a) specific periods of one-to-one teaching in a distraction-free environment
b) brief intensive teaching opportunities that spontaneously occur in the classroom
throughout the day, ensuring:
I) child interacts directly with a trained therapist/teacher,
II) environment minimizes distraction,
III) environment maximizes attention to specific stimuli &
to relevant information for learning and success in learning
(also referred to as augmentative scaffolding),
IV) use of repetition, predictability, and salience
V) use of second-person newly acquired behavior support

VI.) low staff-to-child ration (1:1 or 1:2)
2) systematically generalize skills to more complex, natural environments
a) fade level of prompts (hand-over -hand guidance, modeling, behavior skills)
while gradually increasing the level of the environmental complexity
b) move social behaviors between adult and child to between peer(s) and child
c) change only one feature of the environment at a time during the process of generalization
Provision of predictability and routine:
1) provide highly structured and routine programs
2) rely on assistance of several teachers for systematic facilitation of
a) each child’s use of the environment, and
b) transitions from one activity to another
3) use visual cues
(colored shapes, photos, written words) to label and define specific activities and activity centres
4) reduce distress and confusion during transitions through:
a) ample warning
b) walking the child through the transition
c) providing a transitional object and other visual aids
d) carrying out a familiar ritual during transition
e) use of daily schedules (pictures or written words)
Use of a functional approach to problem behaviors
1) prevent the development of problem behaviors by:
a) increasing the child’s interest and engagement in classroom activities
(increasing fun decreasing problem behaviors)
I) choices of activities
II) include activities that involve highly preferred play materials/topic areas
b) provide highly structured classroom environment to reduce/prevent problem behaviors
I) increase child’s understanding of classroom routine and specific activities
II) promote child’s independence and success
2) understand problem behaviors
a) use functional assessment of problem behaviors
I) make detailed record of behavior
1) situation when it occurred
2) time of day
3) events preceding the behavior
4) how others responded
II) develop hypothesis regarding function the behavior serves for the child
(i.e., communicative function, stimuli provoking function)
3) use a positive response to problem behaviors
a) change the environment to support appropriate behavior
b) teach the child
I) appropriate behaviors to cope effectively with the situation
II) communication skills, including augmentative systems
(words, pictures, gestures, manual signing)
Transition from the preschool classroom
1) teach children “survival skills”(AKA education prerequisite skills) to function as independently as possible in the classroom (which increases successful functioning in a general education environment, and which results in a wider range of post-preschool placements), beginning this many-year process in preschool, including (note – this list is very similar to the education prerequisite skills taught to children with autism at the Alpine Learning Centre):
(basic)
a) complying with adult requests
b) taking turns
c) listening to directions from afar or near
d) sitting quietly during activities
e) volunteering
f) raising one’s hand to solicit attention
g) walking in line
h) using toilets in hallway instead of in classroom
i) picking up toys after use
j) communicating about basic needs
(more advanced)
k) following though with adult instruction
l) sustaining engagement in work activities
m) using a delayed positive reinforcement system
n) moving from one activity to another with minimal assistance
2) assist parents and school districts in finding and preparing for an appropriate post-preschool placement
(to give the child the greatest chance of achieving success in his/her post-preschool placement)
a) preschool teachers help investigate possible placement options
b) preschool teachers assist in finding a placement that is the best match for a child
based on factors such as:
I) class size
II) degree of classroom structure
III) teaching style
c) preschool staff visit the post-preschool classroom and take inventory of the skills
the child will need in order to function as independently as possible
d) preschool program
I) incorporates these skills into the child’s preschool curriculum goals
II) teaches the skills
III) practices the skills
IV) prompts the skills
V) refines the skills
e) families are encouraged to engage children with autism in integrated settings
(religious schools, dance, gymnastics, after-school recreation programs)
I) to evaluate the child’s ability to function in an integrated setting
II) to work on skills the child will need in order to be successful
f) preschool program assists in training the post-preschool staff
g) preschool staff organize gradual transition process:
I) process development:
a) child’s time in preschool program is systematically decreased
b) child’s time in kindergarten or first grade is systematically increased
II process evaluation,
where preschool staff evaluate the child’s performance in the new placement to:
a) identify skill impairments
b) refine skills needed for the new placement
in the familiar and safe environment of the preschool classroom
Family involvement
1) allow families to choose how they want to be involved and which skills they want to work on at home
2) consider parents as critical component of early intervention with children with autism
a) preschool program offers to:
I) teach parents basic techniques of therapy (at home, at school or at both)
II) have parents participate in therapy with their child and a staff therapist
III) encourage parents to continue therapy at home
b) preschool program recognizes that involving parents as co-therapists is a very effective element of autism early intervention since:
I) children with autism make significant progress with trained parents
II) children with autism demonstrate higher developmental skills
when interacting with parents than with therapists,
III) parents can achieve greater understanding of their child’s needs
IV) parents can provide unique insight into creating an intervention plan
V) greater maintenance and generalization skills can be achieved
VI) parents can have an increased sense of competence
VII) parents’ emotional stress is decreased, and well-being is facilitated
3) provide family/parent support groups/counseling
in recognition of the stresses often encountered by families who have a child with autism
Minimum level of intensity
1) provide at least hrs/wk of school-based intervention
2) include home-based intervention, including parent training and support
Augmentative communication
Use a range of augmentative communication methods
Occupational Therapy services
Emphasis on development of trusting, positive social relationships
(rather than focusing solely on the acquisition of specific social behaviors)
Use of typically developing peers
Inclusion of some typically developing peers in some components of the early intervention programs so that they can act as:
a) promoters of social behavior for children with autism
b) positive role models in the classroom
Emphasis on helping the child with autism develop independence, initiative and choice-making skills

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Harris, S.L.& Handleman, J.S. (Eds.), (1994). Preschool education programs for children with autism. Austin, TX: pro:ed.

Summary of essential elements

Rich ratio of adults to children, ranging from 1:1 to 1:3
Parent training and support
Intensive level of services. Group programs ranged from 15 to 30 hours per week and the combination of centre and home-based services is typically more than 25 hours per week.
A combination of centre-based and home-based programs
Some level of integration with nondisabled peers.
Staff including a teacher(s), teacher assistant(s) and direct and consultative services from a speech and language pathologist and psychologist. Many programs also included consultation from an occupational therapist.
Initial and continuing staff training and professional development activities.
Systematic transition planning.
Mean age of admission ranges from 35 to 50 months. (2.9 to 4.3 years)
Development of individualized programs with curriculum content including the major developmental domains, and an emphasis on communication and social interaction.
Positive programming to reduce problematic behaviors.

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Comparison of common features/elements of effective autism early intervention/preschool programs as identified by Dawson and Osterling (1997) (D&O) and Harris and Handleman (1994) (H&H)

Features/Elements identified by both reviews

intensity of program: D&O 15 – 40 hrs/wk of centre based programming, H & H 15 – 30 hrs/wk total home and centre based programming; D& O average centre-based programming 27 hrs/wk, with probable average of total programming 38 hrs/wk, H&H average total programming 25 hrs/wk. Reasonable conclusion: centre-based programming at least hrs/wk, home-based programming at least 5 hours per week for total of at least 30 hrs/wk of intensive, effective early intervention for preschool children with autism.
combination of centre-based and home-based programming: D& O indicate how centre and home programming are combined in their charts and section on Family Involvement. H&H indicate that home components of programming are also part of all effective autism early intervention.
parent training and support: While all programs reviewed by D&O and H&H provide parent training, most offer parent support as well, and D&O articulate why this is an important common element in effective autism early intervention.
systematic transition planning: H&H note that all programs offer transition planning. D&O say the same, but articulate what the transition process entails. They also clarify that the transition process becomes part of the curriculum content for the child with autism.
early admission to programs: D& O average age of admission was 3.5 to 4 years, H&H average age of admission was 2.9 to 4.3 years of age. This requires a prompt process of autism diagnosis between age 2 and 3, so that early intervention is possible.
positive programming to reduce problematic behaviors: D&O & H&H identify that this involves functional analysis of behaviors and a variety of proactive strategies to make environmental adaptations and to teach alternative behaviors and communication skills. It is very important that neither review makes reference to negative consequences (which is the most commonly used behavior reduction strategy). Effective autism early intervention programs place the responsibility for assisting problem behaviors with the staff; the responsibility for changing behavior is not placed on the child. This very different, but clearly effective, strategy requires significant knowledge and experience on the part of the staff, as identified in the D&O review.
occupational therapy services: D&O and H&H both identify OT as a common element of effective autism early intervention, and D&O provide the research-backed rationale regarding motor imitation challenges in children with autism.
Components of common features/elements which are identified in both reviews

rich ratio of adults to children : D&O identifies this as only one component of a Highly Supportive Teaching Environment and Generalization Strategies (which is very detailed) , with a ratio of 1:1 to 1:2; H&H identifies it as separate feature of effective programs, indicating a ratio of 1:1 to 1:3. Conclusion: Since low ratios exist in ineffective programs as well as in effective programs, it is unlikely that it is a causal factor in the effectiveness of an intervention program, unless it is linked with expertise and other common elements of effective programs. However it is clear that low ratios are essential within effective autism programming, preferably at a rate of 1:1 or 1:2, depending upon the needs of the child.
integration with non-disabled peers: D&O indicate that most programs start non-integrated and progress to include some integration with typically developing peers; H&H summary indicates some level of integration in all programs, but the charts indicate that most H&H reviewed programs use progressive integration, which suggests they begin non-integrated and progress to include non-disabled peers, just like the ones in the D&O review. Conclusion: effective autism early intervention programs work toward eventual inclusion of typically developing children with children with autism, with the goal of typically developing children acting as promoters of social behaviors and as role models for children with autism.
curriculum content: D&O Curriculum Content deals with an emphasis on attending, imitation, language, play, social interaction and with the development of pre-requisite skills for post-preschool placement within Transitions; H&H curriculum content includes the major developmental domains, with an emphasis on communication and social interaction. D&O curriculum content is very autism-specific and is presented as the core of what is common between effective autism early intervention programs, while H&H curriculum content is characterized as very broad and non-autism specific, stressing individualization of the curriculum plan. Conclusion: the curriculum of an effective autism early intervention program needs the autism-specific content identified in D&O, along with individual design identified in H&H.
Common Elements/Features not shared between the two reviews

staffing: other than specifying that occupational therapy services are part of effective autism programs, D&O does not specify staffing, but focuses on the required expertise of the staff through the articulation of what is required of them in the delivery of an effective autism program; H&H identifies that staffing is usually teacher(s), speech & language pathologists, teacher assistant(s) for direct services, with consultative services provided by a psychologist and an occupational therapist. Conclusion: while most effective autism programs involve professional staff that usually include teachers, teacher assistants, a speech & language therapist, and involvement of a psychologist and an occupational therapist, the essential common element in staffing is true expertise in knowing what to do to effectively improve the condition of autism in young people, and more importantly, how to do it.
staff training/professional development: D&O does not deal with staff training or professional development, but addresses staff issues only from the point of view that extreme expertise is required. H&H identifies that effective autism programs ensure that there is initial and continuing staff training and professional development. Conclusion: to ensure that autism programs have the requisite level of expertise, staff require initial and continuing training in the specific techniques of the particular program, provided by accredited experts with experience in that particular program.
regular administration of standardized assessments: D&O identify that autism programs use regular assessments of children’s skills and abilities. H&H do not speak about this, but do discuss that programs develop individualized curriculum plans, which leads one to assume that they must be incorporating individualized assessments. Conclusion: Regular administration of standardized assessments to evaluate the skills and abilities of children with autism is an essential component of individualized program development.
specific curriculum content: D&O devote a significant portion of their review to the common curriculum content of effective autism early intervention programs, while H&H state that no firm conclusions can be drawn regarding which types of curricular and instructional components are most effective, due to the lack of control groups in studies (except the Lovaas ABA study, as mentioned in the D&O summary). However the fact is that effective autism early intervention programs have a common autism-specific curriculum, as clearly articulated by D&O, and ignoring that would be imprudent. It is also most interesting to note that all of the programs reviewed by D&O are also reviewed by H&H, so the attention to specific curriculum content exists within the programs in the H&H review. Conclusion: autism-specific curriculum content, as articulated in the D&O review, is an essential element in effective autism early intervention.
highly structured teaching environment and generalization strategies: D&O identify what is involved in effective rich ratio programming for autism early intervention, while H&H do not provide this information. However, like specific curriculum content, the fact is that effective autism programs use highly structured teaching environments and generalization strategies that are designed specifically for children with autism. Conclusion: highly structured teaching environments and generalization strategies, as outlined in the D&O review, are an essential component in effective autism early intervention.
predictability and routine: D&O outline what is required in effective autism programs in recognition of the need for predictability and routine when assisting children with autism, while H&H do not deal with this. Conclusion: with the broad overlap of programs between the two reviews, it is clear that predictability and routine, as identified in the D&O review, are a common feature of effective autism early intervention programs.
augmentative communication: H&H do stress that programs have an emphasis on communication, but D&O go one step further in clarifying that augmentative communication systems should be included as needed. This is significant, as the number of young children with autism without functional communication is very high. It also clarifies that the goal is, indeed, communication, and not limited only to verbal-based communication. This has implications for staffing, as the expertise in augmentative communication is implicit in this goal. Conclusion: with the overlap of programs between the two reviews, the knowledge that most young children with autism have significant communication challenges, and the reality that many people with autism continue to need augmentative communication methods in their lives, use of augmentative communication methods is appropriate as a common element in effective autism early intervention programs.
Emphasis on development of trusting, positive social relationships: While H&H do not deal with the personal element in the programs reviewed, it is noteworthy that D&O have identified this common feature between the effective autism interventions. People who work with young children with special needs have seen that the risk involved in trying something new is often insurmountable for such a child without the existence of trust between the child and the adult interventionist. When a program identifies the development of trust as a priority, then the attitude for working to facilitate the child’s success is implicit. In autism, this is critical for significant improvements to occur, as identified by D&O in their review. Conclusion: effective early intervention programs for autism place emphasis on development of trusting, positive social relationships so that learning can be facilitated.
Emphasis on helping the child with autism develop independence, initiative and choice-making skills: Again, while H&H do not identify this, the outcome goal of regular education placement for as many children with autism as possible identified in both the H&H and the D&O reviews indicates that emphasis on developing independence, initiative and choice making skills is a reality in effective autism early intervention programs. Conclusion: program emphasis on helping the child with autism develop independence, initiative and choice-making skills is a common element of effective autism early intervention.

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Summary of Common/Essential Features of Effective Autism Early Intervention Programs, as identified by Dawson & Osterling and Harris & Handleman

Regular administration of standardized assessments
Autism specific curriculum content, individually developed
1) ability to attend to elements of the environment that are essential to learning
2) ability to imitate others
3) ability to comprehend and use language
4) ability to play appropriately with toys
5) ability to socially interact with others
Provision of highly supportive teaching environments and generalization strategies
(including rich ratio of adults to children)
1) establish core skills in highly supportive teaching environments
2) systematically generalize skills to more complex, natural environments
Provision of predictability and routine
1) provide highly structured and routine programs
2) rely on assistance of several teachers for systematic facilitation
3) use visual cues
4) reduce distress and confusion during transitions
Use of a functional approach to problem behaviors
1) prevent the development of problem behaviors
2) understand problem behaviors
3) use a positive response to problem behaviors
Transition from the preschool classroom
1) teach children “survival skills”(AKA education prerequisite skills)
2) assist parents and school districts in finding and preparing for an appropriate post-preschool placement
Family involvement
1) allow families to choose how they want to be involved
2) consider parents as critical component of early intervention
3) provide family/parent support groups/counseling
Minimum level of intensity
1) provide at least hrs/wk of school-based intervention
2) include home-based intervention, at least 5 hrs/wk
Augmentative communication
Occupational Therapy services
Emphasis on development of trusting, positive social relationships
Use of typically developing peers
Inclusion of some typically developing peers in some components of the early intervention programs
Emphasis on helping the child with autism develop independence, initiative and choice-making skills
Staffing & Staff Training
1) most commonly include teachers, teacher assistants, a speech & language therapist, and involvement of a psychologist and an occupational therapist
2) the essential common element in staffing is true expertise in knowing what to do to effectively improve the condition of autism in young people, and more importantly, how to do it.
3) to ensure that autism programs have the requisite level of expertise, initial and continuing staff training and professional development training are required in the specific techniques of the particular program, provided by accredited experts with experience in that particular program.
Early Admission to programs
Average age of admission is between age 2 and 3, requiring prompt diagnostic process.
Lisa Simmermon
President, Autism Society Canada

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