Treating Autism: Some Better Options

Not long ago I expressed concern about the use of “holding therapy” for autistic children and referenced a blog that had discussed this and come to a more positive conclusion. When supporters of “holding therapy” or other complementary-and-alternative treatments hear of criticisms like mine, they often respond by asking, “Well, what would you do, then? What do you think are effective treatments, if you think this one is ineffective?”

Fortunately, I have some answers to this, in part because of the presentations by Dana Lombardi and Steve Glazier at the April meeting of the Delaware Valley Group of the World Association for Infant Mental Health. Dana discussed Pivotal Response Treatment (PRT) and Steve talked about a treatment developed by the late Stanley Greenspan, Developmental, Individual-difference, Relationship-based therapy (DIR, or DIR/Floortime). Although these treatments come out of different theoretical backgrounds, and although they have differing levels of evidentiary support, they have certain things in common--- particularly their focus on relationships and on the satisfaction of successful communication with other people.

Pivotal Response Treatment (PRT) was derived from Applied Behavior Analysis, the well-known treatment for autism that involves operant conditioning techniques and reinforcement for desirable behavior. Robert and Lynn Koegel of the University of California at Santa Barbara developed PRT as a way to enlist each child’s special motivations and pursue treatment in naturalistic rather than lab-based ways. This means that rather than choosing a behavior to work toward without reference to a given child’s interests, the PRT therapist looks for things the child likes to do and works around those. Then, rather than reinforcing behavior with a generic reinforce like an M & M, the therapist makes the reinforcement relate to the child’s interest and activities. For example, if the child likes to play with balls, the reinforcer for trying to say “ball” is to be given the ball, not to be given food. Some important goals for children in PRT are that they initiate activities more often and that they respond more quickly to events. These and similar changes are expected to make the child’s emotional life more positive. Therapists try to keep children’s interest and motivation high by using different toys or other items and changing tasks within a single activity. They are concerned with fostering goal directed communications--  not just saying a word, but saying a word that will get another person to do something you want. PRT therapists also work to help children manage themselves, by helping them learn to do things like relax their bodies. All of these efforts are intended to work toward giving autistic children the skills to interact with other people, to use language for play and learning, and thus to have some constructive alternatives to frustration tantrums.

PRT is a highly plausible approach whose principles agree with long-accepted evidence about the nature of learning. Its emphasis on pleasurable involvement of parent and child in the treatment is also congruent with much that has been shown about early development.

The PRT model has been supported by research. For example, a paper by N. Nefdt, R. Koegel, G.Singer, and M. Gerber (The use of a self-directed learning program to provide introductory training in Pivotal Response Treatment to parents of children with autism. Journal of Positive Interventions, 12, 23-32) reported a randomized controlled trial in which a treatment group of parents was helped to learn principles of PRT, and the parents and their children’s later behavior were assessed. The treatment group was compared to a control group of families who were on a waiting list for the treatment. PRT was followed by significant increases in language use, as compared to the wait-list group. The advantage of the randomized approach, of course, was that it allowed the researchers to account for any improvement that might have occurred in the natural course of development, without treatment, and enabled them to focus on changes that could be attributed to PRT itself.

The DIR/Floortime model is derived from a combination of psychoanalytic principles and some of the suggestions about cognitive development made by the Swiss theorist Jean Piaget. Three ideas (which I am about to take from Steve Glazier’s handout) are foundational for DIR. One is that “language, cognition (including math and quantity concepts), as well as emotional and social skills are all learned through interactive relationships which involve affective exchanges”. This principle implies that treatment of autistic children should not emphasize specific skills, but that pleasurable and playful social exchanges foster the kinds of development that will later make those skills possible. A second idea behind DIR is that there are individual differences in motor and sensory processing that may make it easier or harder for children to participate in social interaction, and that identifying influential differences can help identify the path to communication with a given child. Third, DIR is based on the idea of a predictable series of developmental stages, each based on earlier experiences; working with a given child requires knowing where he or she is developmentally--   for example, whether the child is able to self-regulate well enough to take an interest in the world without being overwhelmed by it.

Floortime, the primary method of treatment used by DIR practitioners, involves having an adult engage in play with the child for 20 to 30 minutes, on the floor, using toys and objects. The adult’s job is to watch what the child seems to do (even if it’s just looking at an object) and to follow the child’s lead--   perhaps by looking at the same object and then reaching out to touch it gently. Back-and-forth communications are repeated, with the goal of having longer and longer chains of communications, with more and more verbalization and emotional expression. (This is described in more detail at www.icdl.org). Following the child’s lead is a way of engaging with the child’s own motivations, and parents who learn these techniques may be able to escape the “learned helplessness” that has developed in the course of frustrating interactions with their autistic children.

DIR is highly plausible in its emphasis on using the child’s motivation to shape the treatment. It can be considered as using principles of reinforcement, too, as the child’s actions lead to predicable consequences (I use this word to mean “outcomes”, not punishment!) and therefore contain the pleasure of mastery over the world.

Some small pilot studies using randomized controlled trials have supported DIR. For example, a 2011 paper by K. Pajareya and K. Nopmaneejumruslers, “A pilot randomized controlled trial of DIR/Floortime parent training intervention for pre-school children with autistic spectrum disorders” (Autism,15, 583) concluded that training parents to use Floortime resulted in significant improvements on several scales (although language does not seem to have been a focus here). In addition, D.M. Casenhiser, S.G. Shanker, & J. Stieben reported in “Learning through interaction in children with autism: Preliminary data from a social-communication-based intervention” (Autism, 2011) that in a randomized controlled trial DIR helped language development more in children with higher IQs.

Both Floortime/DIR and PRT depend on the training of parents and the parents’ ability to incorporate treatment into the natural family setting. ( Curiously, proponents of holding therapy often complain that in conventional treatments like these, the therapists “blame” parents and interfere between parent and child. ) They also encourage engagement of the parent with the child’s interests and wishes and in this way are opposed to the authoritarian bias of holding therapy and related unconventional treatments. Floortime and PRT are plausible, evidence-based treatments for autism; holding therapy is neither of these. Need I say more?