14 Early Intervention in Autism Geraldine Dawson and Julie Osterling

14 Early Intervention in Autism Geraldine Dawson and Julie Osterling ONE OF THE most exciting recent achieve- and communication. Other subtypes, such as ments in the field of autism is the ability to Asperger syndrome, are being systematically recognize this disorder at a very early age. A identified (American Psychiatric Association, young child with autism can now be recog- 1994). As our understanding of autism nized by difficulties in orienting to social increases, people with milder forms of autism stimuli, impoverished social gaze, and im- are more likely to be identified. As a result, pairments in the areas of shared attention estimates of the prevalence of PDDs are and motor imitation (Curcio, 1978; Dawson climbing. In 1996, it was estimated to be & Adams, 1984; Dawson, Meltzoff, & approximately 15:10,000 people, three times Osterling, 1995; Mundy, Sigman, Ungerer, the prevalence for autistic disorder. School & Sherman, 1986; Osterling & Dawson, administrators are increasingly realizing that 1994). These difficulties pertain to skills more resources are needed to serve young usually evident during the first year of life children with autism and other PDDs. Fortu- and are likely to be apparent by at least 1 nately, there now is a great deal known about year of age (Osterling & Dawson, 1994). As how best to serve preschool-age children with of 1996, efforts are under way to develop autism and related disorders. standardized methods for very early This chapter describes eight examples of identification of children with autism model early intervention programs for children (Lord, Storoschuk, Rutter, & Pickles, 1993). with autism in the United States that have been In the near future, it is likely that early active since the 1980s. These programs are intervention programs will focus on helping reviewed with two goals in mind. The first is to young infants with autism and their parents. address two questions related to the Since the 1980s, we also have gained a effectiveness of early intervention programs better understanding of the tremendous het- for children with autism1: 1) Are the programs erogeneity of the diagnostic category known effective? and 2) Is effectiveness related to the as pervasive developmental disorder (PDD) type or philosophy of the intervention or to (American Psychiatric Association, 1994). characteristics of the child, such as IQ or We now recognize that autistic disorder is verbal ability? This second question is but one subtype of the general category of particularly pertinent to issues related to PDD, this general category being second-generation research (see Guralnick, characterized by qualitative impairments in 1993, and Chapter 1). Based on the available social interaction 1It should be noted that the information on early intervention provided in this chapter is applicable to both children with autistic disorder and children with other diagnoses in the general category of PDD. Many of the intervention programs we review involved both children with autistic disorder and those with PDD, not otherwise specified (see American Psychiatric Association, 1994). outcome research, many children who receive early intervention program for children with early intervention make substantial autism. developmental gains and are able to be included in a general education classroom by the time they enter elementary school. EIGHT MODEL PROGRAMS: Furthermore, there exists little evidence that APPROACHES AND EFFECTIVENESS the philosophy of the program is critical for The eight preschool programs described in this ensuring a positive outcome as long as certain chapter have published detailed descriptions of fundamental program features are present. their philosophies and approaches. In addition, Finally, although it is likely that all children comprehensive intake and outcome data are with autism will benefit from early available for most programs. A brief intervention, it remains unclear whether rate description of each of the programs is provided of progress is related to child characteristics first. Next, the characteristics of the children such as IQ and language ability. entering the programs are reviewed, followed The second goal in reviewing these pro- by a summary of the outcome data. grams is to describe the common elements of existing early intervention programs for chil- Program Descriptions dren with autism. Despite having different Table 1 provides an overview of some of the philosophical backgrounds and approaches, basic program features. A more detailed de- seasoned clinicians and researchers dealing scription of each program follows. with children with autism are shaped by the Douglass Developmental Disabilities Center common experience of working with these The Douglass Developmental Disabilities children. Out of this common experience have Center program (Rutgers University; Han- come basic shared beliefs and methods for dleman & Harris, 1994; Harris, Handleman, helping children with autism. Unless one Kristoff, Bass, & Gordon, 1990) is based on approach is eventually found to be much more principles of applied behavior analysis and effective than another, these shared beliefs behavior intervention approaches. Three dif- and methods may come to be considered the ferent types of classrooms comprise the pro- most basic and essential features of an gram: the "prep" class, the small group class, and the integrated classroom, with children Table 1. Program characteristics Program Program emphasis Hours Inclusion Staff/child 1-to-1 work per ratio weeka Douglass Developmentally sequenced 25 After 1–2 years 1:1 to 4:6:8b Yes Health Sciences Developmental/social-pragmatic 22.5 No 3:6 Yes LEAP Typical preschool—programming 15 Yes 3:6:10b Yes May Developmentally sequenced 30 After 1–2 years 1:1 to 3:6:7b Yes Princeton Individualized behavior programs 27.5 No 1:5 Yes TEACCH Structured teaching Varies Varies Varies Yes Walden Incidental teaching 30 Yes 1:3 Yes Young Autism Discrete trial training 40 Later in 1:1 Yes treatment aDoes not include hours of intervention received at home, except for the Young Autism Program, which provides services at child's home. bRatios are given in order as follows: number of staff/number of children with autism/number of typically developing children. typically progressing over approximately a 3- or psychiatrist during which they can discuss year period from the segregated, highly their child's development and behavior and structured prep classroom to an integrated other areas of concern. Monthly parent sup- preschool classroom. The prep classroom port group meetings are offered, and parents provides intensive one-to-one discrete trial are encouraged to observe and participate in training, based largely on Lovaas' model of the classroom as frequently as they wish. instruction (see Young Autism Program) and Learning Experiences . An Alternative includes both classroom and in-home in- Program for Preschoolers and Parents (LEAP) struction. The small group classroom maintains The LEAP program (Hoyson, Jamieson, & a 2:1 child–teacher ratio and focuses Strain, 1984; Strain & Cordisco, 1994) has two particularly on skills that will be needed to components: an integrated preschool program function in the integrated classroom. The in- (which includes both typically developing tegrated classroom is based in part on Strain's children and children with autism) and a LEAP model (described below) and serves behavior skills training program for parents. children with autism and those developing The curriculum emphasizes a blend of typical typically. A staff member visits each family at preschool activities (e.g., activity areas and home bimonthly. In addition, parents are in- weekly themes) and activities specifically vited to a monthly or bimonthly "clinic" designed for children with autism. The meeting at which all involved personnel primary goal of the curriculum is to expose discuss the child's progress and areas of children with autism to typical preschool concern. The program also offers parent and activities as much as possible and to adapt the sibling support groups. typical curriculum for the children with autism Health Sciences Center The Health Sciences only when needed. Independent play skills and Center program (University of Colorado; social interaction are facilitated by using peer Rogers & DiLalla, 1991; Rogers, Herbison, models and by prompting, fading, and Lewis, Patone, & Reis, 1986; Rogers & Lewis, reinforcing target behaviors. 1989) serves children with autism and PDD as The behavior skills training program well as children with varied behavior disorders. teaches parents techniques for managing their The curriculum is based on developmental child's behavior and teaching new skills. A principles and emphasizes play as an important family service coordinator works with the medium through which socioemotional, family to teach specific target behaviors in a communicative, and cognitive development are natural context, such as the home or com- facilitated. The program also emphasizes munity. Families are also invited to attend a eliciting positive affect within the context of monthly parent support group. social interaction to increase children's attention May Institute The May Institute (Boston; to others and motivation to engage in Anderson, Avery, Dipietro, Edwards, & Chris- relationships. Social relationships are facilitated tian, 1987; Anderson, Campbell, & Cannon, by assigning each child a primary teacher, by 1994) offers a developmentally sequenced fostering close

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