Children with Autism
If you’re an educator in a typical classroom setting or a manager of people in a company, you are most likely using principles of the behavior learning theory in order to shape the responses of those you are instructing. For children with autism, Applied Behavioral Analysis (ABA), which uses the basic principles of the behavior learning theory, is considered a best-practice. If you are teaching children with more complex forms of autism, however, including those with co-occurring medical and psychiatric conditions, using exclusively ABA is no longer considered best-practice or the first line mode of treatment. A program for a child with complex autism requires a combination of biomedical interventions with basic learning theory interventions.
During the last decade a multitude of rigorous scientific and large-scale retrospective studies have demonstrated that many individuals with autism suffer from co-occurring medical conditions (Herbert 2005 and 2014; Lakin & Turnbull 2005; Bauman 2006; Jepson 2007; Coury 2010; Kohane, McMurray, Weber, et al. 2012; Border-Fingert, Brazauskas, Lindgren, et al 2014; Croen 2014; Bresnahn, Horning, Schultz, et al 2015). If these conditions are untreated, especially if the child is in chronic or acute pain and cannot express themselves, they can be the initiating event for a child’s maladaptive behavior (Carr & Smith, 1995; Carr 2002; Buie et al, 2010; Isaksen, et al 2012). Further, undetected medical issues can worsen over time and result in severe and lifelong medical problems.
A common example of such a medical problem is a child who has a sleep disorder such as only sleeping a limited number of hours or getting up frequently during the night. Can that sleep disorder negatively impact the child’s health, functioning, and ability to learn? If the child is chronically sleep deprived they will most likely demonstrate limited attention and irritability, especially with demands that are high or novel. Sleep keeps the mind alert and calm; it is required for optimal alertness. Too little sleep or poor quality sleep is correlated with negative health outcomes.
Another example of a co-occurring medical problem that is highly prevalent in children with autism is chronic constipation. This condition, if untreated, will likely cause pain that can result in maladaptive behavior. Further, if constipation is not treated promptly and/or adequately it can worsen leading to long-term more severe issues with stool passage. Leading scientists and physicians like Dr. Tim Buie a gastroenterologist at Harvard Medical School and Massachusetts General Hospital, and Dr. Beth Malow a neurologist and sleep specialist at Vanderbilt Department of Neurology, are extremely vocal about the correlation between untreated medical issues and their association with pain and suffering as well as their long-term impact on the ability to function.
A BRIEF OVERVIEW
What is Applied Behavioral Analysis?
Applied Behavior Analysis is the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors (communication, social skills, academic, and functional skills) to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior. The defining assumption of behavior learning theory is that behavior increases or decreases as a function of its environment.
Basic principles of behavior learning theory
• Our responses and behaviors are learned
• We learn to maximize pleasure (reward), avoid pain (punishment)
• We are born with certain instinctual responses
• We learn through
– association (classical conditioning)
– consequences (operant/instrumental conditioning)
ABA is a discipline that employs objective data to drive decision-making about an individual’s program. That is, data is collected on responses made by the individual to determine if progress is being made or not; if there is no progress under a particular intervention, there is a need to reevaluate the program and change it so that the child begins to make progress.
What can ABA be used for?
According to the literature, “ABA can be used for almost anything.” If it is thus a behavior that needs to be changed and it can be observed, ABA principles exist that can be used to either increase or decrease that behavior. As a discipline, ABA providers are charged with the improvement of socially significant behaviors.
The Limitations of ABA as a Single Mode of Treatment
ABA has significant limitations when the behavior is not originating from or controlled by an observable environmental event. For children who have complex forms of autism a more robust program is called for. A multidisciplinary team including a physician, psychiatrist, psychologist, neurologist, gastroenterologist, nutritionist and sleep specialist should be called upon to conduct a comprehensive evaluation to determine if the child has medical and/or psychiatric conditions. This is particularly important if the child presents with maladaptive behaviors.
A BIO-BEHAVIORAL APPROACH TO TREATING THOSE WITH COMPLEX FORMS OF AUTISM
An inverse relationship exists between medical problems and acquiring socially significant behaviors.
Medical Problems Socially Significant Behaviors
The current best practice for treating children with complex forms of autism must include screening for, and treating, medical problems as a priority for health and functioning. Attending to a child’s health regardless of whether they are diagnosed with autism or not is foundational for long-term health and sustained learning outcomes. It sets the stage for a child to be able to function well on a daily basis.
The most prevalent medical conditions as documented in the literature, affecting individuals with autism include:
Type 2 Diabetes
Anxiety disorder and chronic stress
Gastrointestinal problems including constipation, diarrhea, mega colon, irritable bowel syndrome, and gastroesophageal reflux disorder (GERD)
Metabolic and immune dysfunction
Nutrient deficiencies/Eating disorder –highly restrictive and selective diets
Psychiatric disorders including OCD, depression, ADHD, and anxiety
What we do at The Center for Discovery
We aim to treat the whole child with evidence-based methods that prioritize treating medical and psychiatric conditions as well as treating the core symptoms of autism using a robust combination of strategies.
All children are screened for a host of commonly occurring medical conditions as documented in the literature. If problems are identified, they are actively treated under the care of an appropriate physician. Methods used to treat medical conditions are best-practice and based on the most current evidence.
The strategies we employ for treating the non-medical core deficits include a multi-method functional behavioral assessment that involves a thorough evaluation of setting events using observation and diagnostic testing, and also using physiological parameters during real-time events. Behaviors that don’t appear to have a clear cause or antecedent or behaviors that are persistent despite behavioral treatment warrant further evaluation for underlying medical causes.
Commonly used components of our best-practice program that support the child in the learning environment include positive behavioral intervention supports (PBIS), naturalistic teaching strategies that teach skills in context as opposed to using a repetitive rote trial method (discrete trial training), modeling and video self-modeling, visual schedules, temporal and environmental organization strategies, functional communication training, story-based interventions, emotional self-regulation teaching using a variety of strategies, scripting and journaling.
Diet is an important factor in the treatment of a child with complex autism. Our dietary strategy is centered on a whole-foods (non-processed) organic diet that excludes as many ingestible toxic substances as possible.
Each child also partakes in a vigorous exercise program to increase their ability to attend and engage in the learning environment. Simultaneously vigorous exercise is used as a strategy to decrease maladaptive behaviors.
Sleep is enhanced by quality food, orderly and structured routines, and vigorous exercise programs, all of which help to reestablish natural circadian rhythms. These components implemented together reduce the chronic stress that the child experiences and helps them to function and feel better.
The curriculum is aligned with the NYS Common Core Standards and is both developmental and functionally-based. Each program is highly individualized, structured and guided by data that is aggregated on an on-going basis. The program is result oriented. If a child is not progressing, the team will meet to conduct a review of the program, and amend the program as necessary.
A child’s core team often includes a physician or nurse practitioner, psychiatrist, gastroenterologist, sleep specialist, nutritionist, master level special educator (may also have BCBA Cert) , BCBA/ Master or Ph.D. licensed psychologist, adaptive physical educator and/or physical therapist, occupational and speech pathologist and the parent.
We do not implement discrete trial training with edible reinforcement and aversive techniques to control behavior. Because of relevant concerns for poor diet, sleep dysfunction, and obesity in this population, edible reinforcement with non-nutritious food (e.g., candy), is not permitted to be used in the program. Punishment and aversive behavioral control techniques are also not permitted.