Primary goals for intervention and treatment are to minimize and alleviate the core features and associated deficits, maximize functional independence and quality of life and alleviate family distress. Myers and Plauche Johnson (2007:1162) state that “facilitating development and learning, promoting socialization, reducing maladaptive behaviours, and educating and supporting families” can all help accomplish these goals.
Autism is not only seen as a medical or biological dysfunction and the International Classification of Functioning, Disability and Health take into account the social aspects of the disability. Environmental factors are included in order to record the impact of the environment on the person‟s functioning and dynamic interaction between the person with this disability and his/her “world”. As a result of this intervention strategies have been progressively oriented towards a psychoeducational approach in which the role of the parents has a great importance (Panerai et al., 2009).
The cornerstones for management of ASD are adequately structured educational interventions, including behavioural strategies and habilitative therapies, which address communication, social skills, daily living skills, play and leisure skills, academic achievement, and maladaptive behaviours (Howlin, 1998; Myers & Plauche Johnson, 2007). One of the most popular methods to treating autism in the recent years has been behavioural based treatment methods. These techniques focused on the use of operant conditioning procedures to increase desired behaviours and reduce undesirable actions (Case-Smith & Miller, 1999). Examples of this therapy include Applied Behavioural Analysis (ABA) and Discrete Trial Training (DTT).
Applied Behavioural Analysis (ABA) is the process of applying interventions based on experimental psychological research to systematically change behaviour and to demonstrate that the interventions used are responsible for the observable improvement in behaviour. Research has shown that home- based early intensive behavioural intervention founded on the principles of ABA can produce dramatic improvements for children with ASD (Grindle, Kovshoff,
Hastings & Remington, 2009). DTT methods establish learning readiness by teaching foundational skills, including attention, compliance, imitation and discrimination learning (Myers & Plauche Johnson, 2007).
Structured teaching for children with ASD emphasises the improvement of skills as well as modifying the environment to accommodate existing deficits. Important elements of this intervention includes (Myers & Plauche Johnson, 2007):
Organization of physical environments, Predictable sequence of activities, Visual schedules,
Routines with flexibility,
Structured work/activity systems and Visually structured activities.
An example of a structured teaching strategy for children with ASD is the Treatment and Education of Autistic and Related Communications- Handicapped Children program, commonly referred to as TEACCH, which modifies and restructures environments to accommodate the unique characteristics of students with autism (Schopler & Mesibov, 1994).
TEACCH takes into account the disorder‟s features and tries to minimize the child‟s difficulties using structured and continuous interventions, environmental adaptations and alternative-augmentative communication. The guiding- concepts of the TEACCH system have been summarized as improved adaptation, parents collaboration, assessment for individualized treatment, structured teaching, skills enhancement, cognitive and behavioural therapy and generalist training. In order to modify the environment to meet the child‟s needs the four main components related to this process include (Panerai et al., 2009:875):
1. Physical organization that refers to the layout or setup of the teaching area for both academic and functional teaching,
2. Visual schedules that show students what activities they will do and when,
3. Work systems that inform students about what and how much activities have to be done, and
4. Task organization that informs students on within-task actions.
This study by Panerai et al. (2009) confirms TEACCH as an effective program for children with ASD as positive outcomes were produced in a natural setting. This study also showed that in order to increase the abilities of children with ASD and to decrease their maladaptive behaviours, their inclusion in a regular class is not sufficient and mainstream schools need to adopt structured teaching and flexibility with the aim of creating the appropriate conditions for an optimal development of children with ASD.
According to Myers and Plauche Johnson (2007) relationship-focused interventions include Greenspan and Wieder‟s developmental, individual– difference, relationship-based (DIR) model, Gutstein and Sheely‟s relationship developmental intervention (RDI) and responsive-teaching (RT) curriculum developed by Mahoney and McDonald. While DIR looks at „”floor-time” play sessions to facilitate emotional and cognitive growth and development, RDI focuses on activities that elicit interactive behaviours in order to develop positive social relationships and a motivation to learn skills to sustain these relationships. RT strategies encourage children to acquire and make use of pivotal developmental behaviours such as attention, persistence, interest, initiation, cooperation, joint attention and affect (Myers & Plauche Johnson, 2007).
Delays in speech and communication can be addressed with the help of speech and language therapists, while occupational therapists promote development of self-care skills and academic skills such as cutting and writing. Sensory integration (SI) therapy remediates deficits in neurological processing and the integration of sensory information to allow the child to interact with the environment in a more adaptive fashion (Myers & Plauche Johnson, 2007).
Autism is a life-long disorder although symptoms can change over the individual‟s life span. These changes are dependent on early detection, intervention and severity of the disorder (Gillberg & Coleman, 2000). Over the past two decades educational intervention has been focused on younger children as there is evidence that earlier identification and early intensive intervention may result in substantially better outcomes with a significant impact on behavioural problems and abilities (Bristol, Cohen, Costello, Denckla, Eckberg, Kallen, Kraemer, Lord, Maurer, McIllvane, Minshew, Sigman & Spence, 1996; Myers & Plauche Johnson, 2007; Panerai et al., 2009).
Detecting early signs of ASD is essential for timely diagnosis and initiation of effective interventions. In addition to improving outcomes earlier diagnosis allows parents the opportunity to receive counselling regarding current estimates of recurrence risk in autism which they may take into consideration in future family planning (Zwaigenbaum, Thurm, Stone, Baranek, Bryson, Iverson, Kau, Klin, Lord, Landa, Rogers & Sigman, 2007).
Pharmacological therapies and medications are best considered ancillary treatments and not remedies or cures. Their advantages must be considered in light of their potential undesirable side-effects and toxicities (Mintz, Alessandri & Curatolo, 2006). Significant improvements to the core symptoms of ASD through psychopharmacotherapy have not been proved (Findling, 2005). However, drug treatments can be utilized in reducing symptoms, improving quality of life and making the child more amenable to non-pharmacological treatments (Malone, Gratz, Delaney & Hyman, 2005). The following drug treatments have been used as an intervention for children or adolescence with autism (Malone, et al., 2005; Steyaert & De La Marche, 2008):
Haloperidol (antipsychotic) is one of the most studied agents in autism and has been found to be effective in reducing hyper-activity, aggression, self-injurious behaviours, temper tantrums, lability of mood, irritability, social withdrawal and stereotypical behaviours.
Risperidone (antipsychotic) has been demonstrated to be beneficial for irritability, repetitive behaviours and aggression but no significant effect on social-communicative features. This drug has been researched
extensively and proved to be significantly superior to the placebo, however adverse effects included weight gain, increased appetite, fatigue, drowsiness, dizziness and drooling.
Olanzapine and Ziprasidone are other antipsychotics used to reduce similar behaviours but research-based evidence for their effectiveness is lacking.
Selective serotonin reuptake inhibitors (SSRIs) are used for depressive disorders and compulsory behaviours in patients with ASD, however their use in children has much been debated as children may be at a higher risk for behavioural activation and disinhibition.
Certain treatment interventions are usually directly related to the perceived cause of the disorder of the individual. For example, the physiological based cause of autism called the “opioid-excess” theory states that maladaptive behaviours by physiological imbalances are caused by incomplete breakdown and absorption of peptides found in food containing gluten and casein (Savery, Shattock, Rodgers & Whitely, 1999). Therefore, dietary intervention would be used in this case, and foods containing gluten and casein would be removed from the diet.
In South Africa, there are institutes and schools that provide a variety of approaches to assisting and teaching children with ASD. These include the following: Alpha, Vera, Growth Through Knowledge, Vista Nova, REACH, SNAP and The Centre for Play and Learning. Parents, with the help of a knowledgeable and experienced professional, can develop a comprehensive and effective therapy plan for their child. This can be done once a thorough assessment of the child‟s cognitive abilities, social-communication skills and aberrant behaviours has been completed. Successful treatment approaches are multimodal and interdisciplinary, using the expertise of paediatric neurology and psychiatry, developmental paediatrics, neuropsychology, behavioural psychology, speech and language, physical and occupational therapies and education. It is critical that therapeutic and education interventions are individualized and tailored to the child‟s specific needs (Mintz et al., 2006).