The Use of Intensive Behavioural Intervention for Children With Autism

Volume 14, Number 2, 2008 Abstract

Autism is a pervasive developmental disorder with prevalence rates increasing yearly. Autism is Authors characterized by impaired social interaction, specific Christina de Rivera language abnormalities, behavioural stereotypes, and a range of cognitive deficits. The presence of CanCog Technologies, Inc. symptoms and the severity impairments vary from Toronto, Ontario individual to individual with deficits ranging from non-verbal and severe intellectual disabilities, to high-functioning. Currently, there is no cure for autism. However, intensive behavioural intervention (IBI) is gaining worldwide popularity as the treatment of choice. Intensive behavioural interventions have roots in applied behavioural analysis. The efficacies of the methodologies that have been used worldwide have varied. This paper compares the original IBI program developed by Lovaas with the current program used by the Toronto Partnership for Autism Services. Research is needed to determine what aspects of IBI are most effective for children with autism, which children benefit the most, if IBI is needed on a continued basis to maintain gains that are made, and if IBI programs are cost-effective for the government.

Correspondence

Christina de Rivera First described by Leo Kanner in 1943, autism christina.derivera@ was considered to be found in children who had a utoronto.ca serious inability to foster relationships with other people before 30 months of age. These children had Keywords abnormal language development and participated in stereotyped behaviours with an insistence on intensive behavioural sameness (Kanner, 1943). Today, it is considered intervention, one of the pervasive developmental disorders and autism, pervasive developmental diagnosis is usually made using the Diagnostic disorders, Statistical Manual IV-TR (American Psychiatric Lovaas method, Association [DSM-IV-TR], 2000) or World Health Toronto Partnership for Organization criteria (World Health Organization, Autism services 1994). (See also Fletcher, Loschen, Stavrakaki, & First, 2007a, 2007b).  de Rivera

In the mid to late 1990s, the prevalence of of a behavioural response affects the autism was estimated to be approximately likelihood that the individual will produce 1 in every 1,000 children (Fombonne, 1999). the behaviour again. According to B. F. Since then, there have been numerous Skinner, behaviour modification “consists reports suggesting that the prevalence of changing the consequences of behaviour, is increasing (e.g., Bello, 2007; Coo et al., removing the consequences, which may 2007; Rutter, 2005; Wing & Potter, 2002). have caused trouble, or arranging new The process of “diagnostic substitution”— consequences for behaviour which has the switching of children with another lacked strength (Skinner, n.d.). According special education classification to autism— to this theory, the consequences of accounts for a substantial proportion of one’s behaviour directly influence the this increase (Coo et al., 2007). However, likelihood that the behaviour will occur the possibility has not been ruled out again (Skinner, 1999). That is, behaviour that increasing prevalence is the result frequency increases when it is rewarded, of environmental factors (e.g., Bello, 2007; and decreases when it is followed by Rutter, 2005). .

Current treatment methods for the There are seven elements that are contained autistic spectrum disorders include in every ABA program (Baer, Wolf, & Risley, the management of associated 1968). First, the program must be applicable. medical problems, pharmacologic and That is, behaviours that are being targeted nonpharmacologic intervention for must have functional significance. Second, challenging behaviours or coexisting the program must include behaviours that mental health conditions, and use of are observable so that performance can complementary and alternative medical be recorded. Third, the program must treatments (e.g., Myers & Johnson, 2007). involve analysis that contains data that The application of intensive behavioural shows that behavioural improvements are intervention (IBI) programs has received due to the therapy. Fourth, the techniques the most attention in the treatment domain. used must be clearly documented so that However, there is currently no cure for another person can easily replicate the autism and no gold standard for therapy. program. Fifth, the program must follow The main focus of this review article is established principles, such as those of to summarize behavioural interventions . Sixth, the program based on applied behavioural analysis should produce changes in behaviour that principles and also to summarize research are relevant to daily living, thus increasing findings about the efficacy of this particular the quality of life of the person. Last, type of behavioural therapy. In particular, changes in behaviour produced during the original program developed by Lovaas the therapy should generalize to other and the Toronto Partnership Autism situations and environments. Services (TPAS) program are discussed. Applied Behavioural Analysis and Applied Behavioural Analysis Autism

Applied behavioural analysis (ABA) is In a talk given by Dr. McEachin and a scientific approach that attempts to summarized by Hultgren (1998), twelve change behaviour systematically using particular behavioural issues in autism the principles of operant conditioning. were outlined, and ways in which those Operant conditioning is a training or issues could be resolved using the learning process by which the consequence principles of ABA were proposed.

JoDD IBI For Children With Autism 

1. Children with autism are often not highly Consequently, it is imperative that motivated. Thus, ABA should focus on lessons be as interesting as possible so making learning tasks interesting so that that the therapist is able to hold the the child will be motivated to learn the child’s attention. task. This means that if the child has 6. Sixth, children with autism have difficulty correctly learned the task, the positive understanding abstract concepts. It is consequence associated with learning essential that the therapist use simple, the task should be clear and sufficiently clear, and concise language so the child different from the negative consequence is able to follow the directions necessary of not having learned the task. In this to learn and perform the task. way, the child is able to see the cause 7. Children with autism have difficulty and effect relationship between correct learning by observation. This drives the learning of the task and its associated previous point about how children with positive consequence. According to autism need simple, clear, and concise the theories of operant conditioning, instruction about how to perform certain consequences normally have behavioural tasks. associated with them (Skinner, 1999). 8. Children with autism have difficulty differentiating relevant stimuli from 2. Children with autism need tangible irrelevant stimuli. It is very important reinforcements. According to Dr. for the therapist to draw the attention McEachin, social reinforcements, such of the child to relevant stimuli so that as words of approval, are not usually he or she is able to make the correction sufficient to elicit the target behaviour. stimulus-response relationships. Making Instead, children with autism need connections between the stimulus, tangible reinforcements, such as edibles one’s response, and its consequence is or time to play with their toys. fundamental for effective behavioural 3. Children with autism have very short intervention based on ABA principles. attention spans. Thus, to ensure maximal 9. Children with autism often partake in effectiveness of behavioural treatment, behaviours, such as self-stimulation, that ABA breaks tasks down so that small can interfere with their learning. Thus, steps can be learned at a time. the first goal of the therapist is to stop 4. Children with autism are also easily the interfering behaviour so that he or distracted. Therefore, ABA therapy she can concentrate on teaching the task. initially takes place in a quiet environment This way, the child is able to devote 100% with few to maximize of his or her attention into learning the learning potential. The eventual goal of task. the therapy, however, is to be able to 10. Children with autism learn better in generalize the behaviours learned during small groups. Because of this, most ABA ABA therapy to more natural settings, therapy is performed on a one on one such as play time or at school. Thus, basis. The ratio of children to therapist is as children become more successful in only increased once the child has shown performing a specific task, therapy may that he or she is able to learn in a one on move to more naturalistic environments. one setting. 5. Aside from learning difficulties due to 11. Children with autism do not use free attention span, children with autism time effectively. For this reason, ABA generally learn more slowly. Therefore, therapy is very structured, and to keep children with autism need a lot of the therapy interesting play skills are repetition to learn a particular task. incorporated into the schedule.

v.14 n.2  de Rivera

12. Children with autism have sensory and/ child, preferably between the ages of 3½-5 or motor impairments. Thus, ABA therapy years. Due to the intensive nature of the incorporates that which stimulates motor therapy, parents are trained by therapists skills and all the senses. versed in the program so that the parents are able to deliver the therapy at home. In this way, the children are essentially Applied Behavioural Analysis immersed in the therapy during all the Based Programs for Children With hours that they are awake. For maximal Autism efficacy, therapy is performed on a one- on-one basis for 6-8 hours per day, 5- Intensive behavioural interventions (IBI), 7 days a week, for 2 or more years. also known as early intensive behavioural Built into the 40 hours/week of therapy interventions (EIBI), are programs based are scheduled breaks such as naptime, on the principles of ABA that have been meals, and playtime. Due to the learning designed specifically to help children with difficulties of children with autism (see autism. Thus, the conceptual basis of IBI is above), systematic behavioural teaching operant conditioning (Lovaas, 1987). It is methods, such as a highly intensive form of ABA that has (DTT), are used to break down each skill been associated most with autism. so that it can more easily be learned (Sheinkopf & Siegel, 1998). The Lovaas Method Discrete Trial Training ABA principles were used by Dr. Lovaas to develop his model of behaviour Therapeutic sessions in the Lovaas model modification while at the University of are taught using a series of discrete trials California in Los Angeles (UCLA) to called units (Sheinkopf & Siegel, 1998). improve the behaviour of children with Since children with autism have short autism. The Lovaas model is detailed in attention spans, learn more slowly, and a training manual (Lovaas et al., 1981) have difficulty understanding abstract and accompanying videotapes (Lovaas & concepts, learning a new skill is divided Leaf, 1981) that assist parents in correctly into short units. Each trial consists of implementing the model at home. The three parts: a stimulus (also known as an first stage of the Lovaas method involves instruction), a response, and a consequence improvement of basic self help and (also known as feedback). An example of a language skills. Improvements of non- skill to be learned is being able to look at verbal and verbal imitation skills are the therapist when asked. In this scenario, practised. Once this is attained, therapy the stimulus or instruction can be the moves towards toy play. The second stage therapist asking the child to look at him involves working on expressive and early or her. The response can be one of two abstract language and interactive play things: 1) the child may turn to look at the with peers. Once a child has reached the instructor or 2) the child may not make a advanced stages of the program s/he may move at all. The consequence or feedback be integrated into schools for normal depends on the response. If the child looks, functioning children. the therapist may reinforce the correct behaviour by praising the child and giving The Lovaas method was further refined him or her an edible. This feedback occurs based on evidence from the Young Autism immediately after the response so that Project in UCLA (Lovaas, 1987). From the child can easily draw the stimulus- this study, it was established that therapy response-consequence connection. should begin as early as possible with the

JoDD IBI For Children With Autism 

Interestingly, constant use of is not independent from those involved in the advocated by Dr. McEachin (Hultgren, study. Second, the children had to be 1998). He stresses that verbal feedback less than 46 months of age, or less than should be reserved for letting the child 40 months if mute. The reason for this know that he or she has made an incorrect early age target was twofold. First, Dr. response. This can be done by forcefully Lovaas believed that children before and clearly saying no right after the the age of four would be better able incorrect response. If the child does not to generalize what they learned at the look, the therapist may say the instruction clinic to different environments compared again, this time using a prompt. A prompt with older children. Dr. Lovaas assumed is used to demonstrate the correct response that such transfer of learning would be to the child. In this example, the therapist harder for older children to accomplish. may use a physical prompt. That is, he Second, it was assumed that it would be or she could place his or her hand on the easier to integrate younger children into child’s chin to guide the child’s focus. A mainstream schools while still young. therapist does not wait long for the child’s Participants were placed in one of two response – a prompt may be used after just groups: an intensive treatment group that 5 seconds of the stimulus. However, one of received more than 40 hours of one-on- the goals of therapy is to have the child one treatment per week for more than 2 respond to the stimulus without prompts. years, or the control group that received Thus, as therapy progresses, prompts are 10 or fewer hours of treatment per week used less often. for more than 2 years. A third group, considered the second control group, An important aspect of Discrete Trial was also included in the data analysis. Training is to evaluate whether or not These were children with autism who the therapy is working. That is, the child were not receiving IBI. Each group had with autism has to show measurable 19 participants. Pretreatment measures and observable changes. These changes included conducting standardized tests need to be quantifiable to demonstrate a to determine mental age, behavioural cause and effect relationship between the observations based on videotapes intervention and the outcome (Hultgren, about self-stimulatory behaviours (i.e., 1998). Finally, an important part of ABA ritualistic, repetitive and stereotyped), play that is built into the therapy and in the behaviours, and the use of recognizable outcome measure is to determine how words. Further information about language generalizable the skills that have been development was gained from a one hour learned are in non-therapy situations parent interview. During this interview, (e.g., during playtime). A truly successful parents were also questioned about other intervention is considered to be the child pertinent behaviours and demographic being able to enter mainstream schooling information. (Lovaas, 1987). Intensive behavioural intervention was Research Support for the Lovaas Method performed by student therapists trained at UCLA. However, parents were also The first report on the efficacy of IBI in extensively involved so they could children with autism was published in administer the techniques as often as 1987 (Lovaas, 1987). To be eligible for possible. The actual treatment procedures this study, the participants had to meet were not detailed in the paper, except to two criteria. First, they had to have been say that treatment occurred for a total diagnosed with autism by an individual of 40 hours in the child’s home, school,

v.14 n.2  de Rivera and community for 2 or more years. Further evidence of the efficacy of this Details of the treatment procedures had method was reported in a follow up study been outlined previously in a separately in 1993 (McEachin, Smith, & Lovaas, published teaching manual (Lovaas et al., 1993). In this paper, McEachin et al. (1993) 1981). An excerpt from the paper does, assessed the same experimental group however, describe how aggressive and from Lovaas’s 1987 paper. At the time of self-stimulatory behaviours were dealt assessment, the children had a mean age with. Strategies included: ignoring the of 11.5 years. Eight of the original nine behaviour, use of a time-out, shaping a children that were assessed as having more acceptable form of behaviour, or as a above average or average IQ could not be last resort, saying a loud “no” or slapping differentiated from typically developing the child on the thigh (Lovaas, 1987). children in terms of IQ or adaptive behaviour measures. The same could The first year of the therapy concentrated not be said about the control group that on reducing both aggressive and self- had minimal treatment. Thus, this study stimulatory behaviours. The therapists also reported that the Lovaas method of IBI tried to teach the children how to properly (Lovaas et al., 1981) produced long lasting comply with verbal requests, imitation, positive changes (McEachin et al., 1993). and appropriate play. The second year of This was the first study to demonstrate treatment had a greater focus on verbal the long term effects of the Lovaas model language development. The third year of IBI. focused on teaching skills that would be necessary for integration into the school Other Research With Successful setting. These included: proper expression Outcomes of emotions, reading, writing, arithmetic and observational learning. Since the landmark study published by Lovaas (1987) and the follow up study published The reported results of this study are by McEachin et al. (1993), other researchers astounding. By the age of seven, nine of have reported similarly positive outcomes the nineteen children (i.e., 47%) in the using the Lovaas method; albeit no study has experimental group passed first grade reported results as successful as those claimed for typically developing children and had by Lovaas. intelligence quotient (IQ) scores that were average or above average for their age. The same year the McEachin study was Eight of the remaining ten students passed published, Birnbauer and Leech (1993) the language delayed class with IQ scores published a similar study that looked in the range typical of children with mild at the treatment of nine boys for two intellectual disability. The remaining two years using the Lovaas method versus a subjects in the experimental group had IQs control group of five boys. Therapy was in the profoundly disabled range and were conducted for approximately 29 hours placed in a special class. In contrast, only at home by various trained volunteers. one child from both control groups achieved The study reported that 4 of the 9 boys normal functioning, that is, this child had non-verbal IQ scores of 89 or higher, passed first grade for typically developing with language levels in the experimental children and had average IQ. Half of the group double that found in the control remaining children in the control groups group. However, how well the children had IQs in the mild intellectual disability were functioning is difficult to ascertain range and the other half had IQs in the directly from non-verbal IQ scores. profound disability range.

JoDD IBI For Children With Autism 

The first study to report using the Lovaas in the Lovaas et al. (1981) manual, it method in a parent directed home-based was not until the year 2000 that a study setting was published in 1998 (Sheinkopf & was published comparing the efficacy of Siegel, 1998). The importance of this study intensive behavioural intervention versus is twofold. First, treatment in the Lovaas parent training (Smith, Groen, & Wynn, (1987) and McEachin et al. (1993) studies 2000). This study is also novel in that were administered by university students. it included not only children diagnosed In fact, university-based interventions are with autism but also those diagnosed with known to be very effective (Casey & pervasive developmental disorder not Berman, 1985; Weisz, Weiss, Han, Granger, otherwise specified (PDD-NOS). The IBI & Morton, 1995). Thus, it remained to be group (n = 15) received approximately 25 proved whether the Lovaas method would hours per week for one year of individual be effective if therapy was performed by therapy from UCLA trained therapists, parents in a home setting. Second, both the with hours being gradually reduced over Lovaas (1987) and McEachin et al. (1993) the next one to two years. By comparison, studies were subject to much controversy the parent training group (n = 13) received (Boyd, 1998; Gresham & MacMillan, 1998; 5 hours/week of training in their homes Kazdin, 1993; Mesibov, 1993; Mundy, 1993; for 3 to 9 months. Schopler, Short, & Mesibov, 1989). Thus, more studies needed to be done to fully This study was also the first to report establish the efficacy of the Lovaas model fidelity to treatment methods as described of IBI (Lovaas, Smith, & McEachin, 1989; in the Lovaas et al., (1981) manual. Smith & Lovaas, 1997; Smith, McEachin, Nonetheless, methodological differences & Lovaas, 1993). A prospective study by between this study and the landmark Sheinkopf and Siegel (1998) focused on Lovaas (1987) study existed: 1) IBI was a treatment group receiving IBI that was less than 40 hours/week; 2) parents were drawn from a larger longitudinal study on not required to participate as extensively autism. According to parent reports, eleven as was required of the parents in the children from this pool had been receiving 1987 study; and 3) the use of contingent the Lovaas method of IBI. These children aversives, found to be a significant factor were then age-matched and mental age- in the 1987 study (Lovaas, 1987), was matched with 11 control children for data discontinued after a brief trial with four analysis. The results showed that children children. Results from this study show with autism who were receiving Lovaas that children receiving IBI outperformed style IBI had significantly higher IQ scores the parent training group on measures of (mean difference of 25 points) compared intelligence, visual-spatial skills, language with the control group (Sheinkopf & and academics. Siegel, 1998). Interestingly, such gains were still found even though the experimental One premise that has been followed by all group received less than 40 hours of of the studies discussed so far has been therapy (mean = 19.45 hours), and IBI had the strict adherence to the recommended only been going on for about 15 months. age range as reported in Lovaas’s 1987 However, from this study it remains study. Thus, it was unclear if the Lovaas unclear if such cognitive gains resulted in method would provide any benefit to changes in adaptive behaviour, and thus children older than four years of age. an improvement in quality of life. This particular question was addressed by Eikeseth, Smith, Jahr, & Eldevik (2002). Although many parents were starting These researchers compared behavioural to follow the Lovaas method as detailed treatment of four to seven year olds for

v.14 n.2  de Rivera one year using IBI as described in the expected to: 1) conduct assessment tests Lovaas 1981 manual and videotapes, to confirm eligibility for the program; except there was no use of contigent 2) create an individual service plan that aversives (n=13) to that of another form would be followed; and 3) ensure that of intensive therapy called the eclectic the treatment being received was based treatment (n=12). Eclectic treatment on best practices (Integrated Services for incorporated methods from Project Children’s Division, 2000). Parents had TEACCH (Schopler, Lansing, & Waters, the option of receiving services from the 1983) and sensory integration (Ayres, 1972) regional centres or going to a private along with the Lovaas method (Lovaas et centre by opting for the direct funding al., 1981). Both treatment groups received option. With this option, parents received similar amounts of therapy (mean = 29 the funds for IBI therapy directly. The hours) and both treatment methods were parents were then in charge of allocating administered at school. The researchers payment to the therapist. found that even older children can indeed benefit from Lovaas style IBI. The IBI The program was created because of the group made significantly greater gains in evidence that has been reported over IQ and communication scores compared the years about the efficacy of Lovaas with the eclectic treatment group at the style treatments. However, the Ontario one year follow up (Eikeseth et al., 2002). program is unlike the Lovaas method. A very recent followup study confirmed The only factor in common between the and extended these preliminary findings, Ontario program and the Lovaas method suggesting that behavioural treatment was is that both are based on the principles of more effective than the eclectic treatment ABA (Sardi, 2005). See also Gindi (2004); for children with autism in the study Perry (2003); and, Perry and Condillac (Eiseketh et al., 2007). (2003) for additional information about IBI and best practices in autism.

The Government Mandate for To enhance the success of the RIEIPCA, Children With Autism in Ontario the program set out guidelines based on previously successful research (Program The model of behavioural intervention guidelines for regional intensive early for children with autism developed by intervention programs for children with Dr. O. Ivar Lovaas in the United States autism, 2000). is the pioneering method of intensive behavioural intervention. His method has 1. The program must begin early. As received worldwide attention. For example, such, only those under six years of age in the United Kingdom, about 250 Lovaas- were eligible for these government paid style programs had been established as services. of 1999 (Johnson & Hastings, 2002). In Ontario, in the fall of 1999, the government 2. The program must be intensive, with announced that it would fund a province- research suggesting between 20-40 hours wide initiative to support young children per week for a period of at least 2 years. with autism to receive early IBI. The The RIEIPCA recognized, however, that program was called: Regional Intensive there may be variations to this amount Early Intervention Programs for Children because of factors such as the child’s age, with Autism (RIEIPCA). In the spring and tolerance for the level of intervention, summer of 2000, nine regional centres stage of treatment, rate of progress, and that would administer this program were the level of participation that the family selected. These regional centres were was willing to undertake. This was in

JoDD IBI For Children With Autism  contrast to the clear guideline in the The Toronto Partnership for Lovaas method that therapy must be for Autism Services at least 40 hours a week. The strongest evidence for effectiveness of therapy The Toronto Preschool Autism Service using the Lovaas method was also (TPAS), which now is called the Toronto demonstrated when therapy was set at 40 Partnership for Autism Services program, hours a week (Lovaas, 1987). What was provides a centre based program (Sardi, unclear, however, was whether or not 2005; Surrey Place Centre, 2007). This is in breaks such as meal and naptimes had line with previous practice that has found been incorporated in the recommended most behavioural intervention therapies times outlined by the RIEIPCA. occur in the clinic (Scotti, Evans, Meyer, 3. Systematic behavioural methods must be & Walker, 1991). Therapy across various used to teach skills, and these skills must settings reinforces the fact to the child that be generalizable. what he or she has learned is not limited to a particular situation, thus contributing 4. The child’s progress must be measurable to the development of generalization. so that program changes can be based on For children involved with centre based evidence of the child’s development. therapy, such as those that belong to TPAS, 5. The curriculum must be comprehensive it is important that parents are involved and must follow a developmental in the treatment. In this way, even at sequence. home the parents are able to practise the 6. The schedule should be predictable and principles being addressed during therapy structured. The programming must also time at the centre. Indeed, the ultimate allow for the opinions of the child and goal of the program is to be able to achieve the parents. developmental levels that will allow the 7. Each program must be individualized child with autism full integration into a based on the child’s ability and the school for typically developing children parents’ goals for the child’s development. with minimal supervision. This means Program intensity is determined by the that therapy would move from the one- therapist in consultation with the values on-one situation composed of the child of the parents. Furthermore, stimuli and and his or her therapist to a group setting reinforcements used are all decided in where most of the instruction is coming consultation with the parents so that from the classroom teacher. they are applicable to child’s likes and Although provincial guidelines have been dislikes. set about the goals of IBI in Ontario, some 8. Therapy must be delivered by highly differences exist among the programs trained instructor therapists. The in Ontario. For example, parents have therapist has to implement and track the the opportunity for direct funding. With progress of each child that is under his or this option, children may have therapy her care. The therapist is responsible for at home, unlike those children enrolled making changes to the program based on in TPAS. Thus, it would be misleading to the measures being taken. The therapist speak of an Ontario Program of IBI. is supervised by a senior therapist who ensures that the program is being Unlike the Lovaas method, TPAS puts a followed and implemented according to predominant emphasis on the analysis of government standards. verbal behaviour. The program is guided 9. The therapy must occur in a variety of by research from Dr. Mark Sundberg, Dr. settings. James Partington, and Dr. Jack Michael

v.14 n.2 10 de Rivera (Sundberg & Michael, 2001; Sundberg Some Approaches Used in TPAS & Partington, 1998). These authors have developed programs with roots in ABA. Teaching Language Using IBI Thus, both the Lovaas method and TPAS are rooted in the same principles. The Early interventions for teaching language primary assessment tool being used to most often use DTT methods on a one- develop a language program in TPAS is on-one basis using flashcards as stimulus the Assessment of Basic Language and (Koegel, Bimbela, & Schreibman, 1996). Learning Skills guide (ABLLS). The ABLLS As mentioned previously, DTT breaks contains task analysis for the many skills complex skills down into parts so that necessary to communicate successfully they can be learned more easily. Early and to learn from everyday experiences indications were that this method was not that have been specifically formatted for shown to be efficacious (Lovaas, 1977), children with language delays (Partington as language gains were minimal and & Sundberg, 1998). what was learned during clinic did not generalize to more natural environments. Although originally intended for very On the contrary, it has been argued that young children with severe autism, TPAS initial language skills specifically may now provides educational support for be taught using this format (Sundberg & parents, and transition services to provide Partington, 1998). support for children who are in treatment to move into new environments, including For example, these researchers suggested schools and community centres. See the that a nonverbal child with autism should Ontario Ministry of Education Report first be taught how to request or ask for #140 (2007) for details about the school an object (Sundberg & Partington, 1998). program. The specific goals of the IBI The method follows a social-pragmatic program for children in TPAS are to developmental approach (Prizant & improve language and communication Wetherby, 1998). The researchers claimed skills, promote self-help abilities, increase that this is an excellent starting point as appropriate behaviours while decreasing the command intrinsically has a built- challenging behaviours, and build social in ; that is, the child is skills. IBI programs are delivered by given the item that he or she requested. highly-trained specialists on a one-on- If the object picked to be requested is one basis or in small groups. At least one that the child particularly likes, this 20 hours of therapy are required each is further reinforcement. During initial week. Parents play an important role in training, a set of objects is chosen. These the success of the program. TPAS offers objects must all be desirable to the child. specialized training to parents so they Equally important, these objects must be can help their children reach each goal. significantly different from one another The IBI program is customized to meet the by name and sight so that the child is not learning needs of each child. Individual easily confused about which object is the program goals are established according topic of the command. Also, in the initial to each child’s unique strengths and needs. part of the training, the desirable object is The methods of instruction are tailored to always within the child’s field of vision. the child’s behaviours and needs. Each Thus, the child always sees the object that child’s progress is measured at regular he or she is being asked to ask for. Once periods and the program is adjusted to the child has been trained to ask for the reflect any changes in the child’s learning objects that he or she likes, the next step (Surrey Place Centre, 2007). is to remove the object from the child’s

JoDD IBI For Children With Autism 11 field of view. This is done in a systematic object: its shape, size, colour, or texture. So, manner. First, the child will be prompted following with the bear example, features to ask for the object. For example, the would include such things as feels furry, therapist may ask the child what object has legs and arms, and has brown eyes. he or she wants. The more a child learns Classes are the larger group to which the to ask for the object, the fewer prompts object belongs. Thus, the bear belongs to are given by the therapist. Once the child the class of animals. is able to ask for the object without the object being in his or her field of view and In an attempt to make language ability without prompts, the child is considered to learned in the centre generalize to have mastered the command task. Finally, other situations, the social-pragmatic the desired language response must be developmental approach described practiced in natural environments to above has been slightly modified. The promote generalization of the skill. natural language paradigm has six main components (Koegel & Koegel, 1995). First, After learning five to ten commands the teaching is child-directed. That is, the child moves on to learning how to name therapist initiates teaching conversation objects (Sundberg & Partington, 1998). only when the child attends to the target The same principles used in learning how object or if the child makes an attempt to make commands are used in learning to communicate about the target object. how to name objects. First, the objects Second, to promote generalization, to be named must be objects that are of teaching only occurs in natural settings. interest to the child. Second, the objects Third, prompts such as time delay and to be named must be sufficiently different verbal prompting are used to promote from each other and must have names language development. Fourth, natural that will not present too much difficulty consequences are used (Koegel & Koegel, for the child. In fact, researchers suggest 1995). That is, if the child asks for an that the command objects are a good object, he or she is given that object. Fifth, place to start the naming task as the child all attempts at the target communication is already familiar with these objects. At are reinforced. These include inaccurate first, the teacher may use verbal prompts attempts that are also shaped. Sixth, the to increase the child’s correct response paradigm emphasizes natural interactions, rate. For example, the therapist may say, such as turn-taking. The natural language “Give me (name of object). What’s that?” paradigm has been shown to be equally effective at developing articulation when Concurrent with learning how to name compared to more traditional approaches objects, children also learn how to to language development (Koegel, receptively discriminate between these Camarata, Koegel, Ben-Tall, & Smith, objects, for example, by touching a 1998). However, Koegel et al. (1998) found specific object that has been requested. that only the natural language paradigm This is evident in the prompt used in generalized articulation improvement in the previous naming the object example. a conversation. Receptivity is taught in three different ways, by: function, features, and class. The Picture Exchange Communication To demonstrate the use of function, for System example, if the therapist is asking the child to touch his or her toy bear, the therapist Another program used by TPAS is the may say, “Touch the thing you play with.” Picture Exchange Communication System Features relate to characteristics of the (PECS) (Frost & Bondy, 1994). Similar

v.14 n.2 12 de Rivera to the natural language paradigm, the community with much hope about the main emphasis of the program is to elicit positive outcomes their children may spontaneous communication. In the initial experience if they undergo IBI. However, phase of the program, an extra person is these studies are not without controversy needed by the therapist to help teach the (Boyd, 1998; Gresham & MacMillan, 1998; child. In a given trial, the therapist holds Kazdin, 1993; Mesibov, 1993; Mundy, 1993; an object desirable to the child on one Schopler et al., 1989). Thus, more studies hand while on the other hand he or she need to be done to fully establish the holds a card with a picture of the object. efficacy of IBI in autism. Although several The extra person positions him or herself published studies have reported positive behind the child, physically prompting the outcomes (Birnbauer & Leach, 1993; child, if necessary, to pick up the picture Sheinkopf & Siegel, 1998; Smith, Buch, card. If the child reaches for the object, the & Gamby, 2000) using the Lovaas et al. therapist gives the picture card instead. (1981) manual, as have other IBI programs Once the child has the picture card, he including TPAS (Ben-Itzchak & Zachor, or she is encouraged to give it back to the 2006; Eikeseth, Smith, Jahr & Eldevik, therapist by putting it in the therapist’s 2002; Eikeseth, Smith, Jahr & Eldevik, 2007; hand. The therapist prompts the child to Freeman & Perry, 2006; Remington et al., give the picture card by showing him or 2007), none have reported gains to normal her an open hand. When the card reaches functioning as found in the Lovaas’ 1987 the therapist’s hand, he or she says, “I study. Outcome studies of the Ontario want (name of object on the picture card).” autism program will thus be of great Physical prompts are decreased until the interest. Issues that should be examined child is able to reach for the card in 80% of include: determining what elements the trials. Lastly, open hand prompts are of the IBI program are most effective, decreased until the child initiates giving including qualifications of the instructors the picture card to the therapist in 80% of and quality of instruction; identifying the trials. the characteristics of the children who most benefit; and clarification on whether Teaching Schedules Using Intensive continual IBI is needed to maintain Behavioural Intervention achievements, and, if so, for how long. Perhaps most importantly, a question that Besides language delay, a second major needs to be addressed is whether or not issue with children with autism is that IBI programs are cost-effective (i.e., in they very often are unable to follow routine the long-run, are they cost-saving to the independently. Thus, most children need government). Such information will be to be supervised at all times, and most very important to the government when activities are initiated and completed with it comes time for reassessing the program adult prompts. Thus, teaching schedules is for continued funding. Such studies also part of the TPAS program. As an example, will provide parents with a clearer picture McClannahan & Krantz (1999) described about what to expect from this treatment the use of picture activity schedules as a method. means for development of independence of children with autism. References

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