EMPIRICALLY SUPPORTED

TREATMENTS FOR AUTISM

SPECTRUM DISORDER
Benson G. Munyan, III, B.S.
Child EST
DIAGNOSTIC CRITERIA FOR ASD (DSM-5)
 A. Persistent deficits in social communication and social interaction across
multiple contexts, as manifested by the following, currently or by history
(examples are illustrative, not exhaustive, see text):
 1. Deficits in social-emotional reciprocity, ranging, for example, from
abnormal social approach and failure of normal back-and-forth
conversation; to reduced sharing of interests, emotions, or affect; to failure to
initiate or respond to social interactions.
 2. Deficits in nonverbal communicative behaviors used for social
interaction, ranging, for example, from poorly integrated verbal and
nonverbal communication; to abnormalities in eye contact and body
language or deficits in understanding and use of gestures; to a total lack of
facial expressions and nonverbal communication.
 3. Deficits in developing, maintaining, and understanding relationships,
ranging, for example, from difficulties adjusting behavior to suit various social
contexts; to difficulties in sharing imaginative play or in making friends; to
absence of interest in peers.
 Severity is based on social communication impairments and restricted
repetitive patterns of behavior.
DIAGNOSTIC CRITERIA FOR ASD (DSM-5)
 B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested
by at least two of the following, currently or by history (examples are illustrative, not
exhaustive; see text):
 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g.,
simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic
phrases).
 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns
or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food
every day).
 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g,
strong attachment to or preoccupation with unusual objects, excessively
circumscribed or perseverative interest).
 4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects
of the environment (e.g., apparent indifference to pain/temperature, adverse
response to specific sounds or textures, excessive smelling or touching of objects,
visual fascination with lights or movement).
 Severity is based on social communication impairments and restricted, repetitive
patterns of behavior.
DIAGNOSTIC CRITERIA FOR ASD (DSM-5)

 C. Symptoms must be present in the early developmental period (but may not
become fully manifest until social demands exceed limited capacities, or may
be masked by learned strategies in later life).
 D. Symptoms cause clinically significant impairment in social, occupational, or
other important areas of current functioning.
 E. These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) or global developmental delay. Intellectual
disability and autism spectrum disorder frequently co-occur; to make comorbid
diagnoses of autism spectrum disorder and intellectual disability, social
communication should be below that expected for general developmental level.
Thus, the target of treatments for ASD should be theoretically driven
to address difficulties in the follow broad domains:

Social Communication and Interaction

Restricted/Repetitive Patterns of Behavior
ASSESSMENT INSTRUMENTS

 Autism Diagnostic Observation Schedule, 2nd Edition (ADOS-2)

 Ages 1+
 40-60 minute administration time
 Semi-Structured, Standardized Assessment
 Gold-Standard
 r = >0.6 (Good)
 Assesses communication, social interaction, and play.
Skip to 1:51
ASSESSMENT INSTRUMENTS
 Autism Diagnostic Interview – Revised (ADI-R)
 2+
 90-150 minutes (Including scoring)
 Semi-Structured Interview
 Developmental framework and current functioning
 Gold-Standard
 r = >0.6-0.89 (Good)
 Assesses communication, social interaction, and repetitive
behaviors.
ASSESSMENT INSTRUMENTS
 Vineland Adaptive Behavior Scale
 Assesses adaptive level of functioning.
 Communication, Daily Living, and Socialization

 Childhood Autism Rating Scale

 Ages 2+
 Standard and High-Functioning Versions
 5-10 Minute Response Burden

 Gilliam Autism Rating Scale – Second Edition (GARS-2)

 Ages 3-22
 Assesses Stereotyped Behavior, Communication, and Social Interaction
ASSESSMENT INSTRUMENTS

 Bayley Scales of Infant Development – 2nd Edition (BSID-II)

 Assesses early childhood development.
 Three Scales: Motor, Mental, and Behavioral
 Age based norms
 Test-Retest (0.88)
 IRR (0.96)
PHARMACOLOGICAL INTERVENTIONS
There are no medications that can cure ASD or treat the core symptoms.

However, there are medications that can help some people with ASD function better. For
example, medication might help manage high energy levels, inability to focus,
depression, or seizures.

(Centers for Disease Control and Prevention, 2015)

Pharmacological treatments for autism generally target psychiatric symptoms, rather

than core autistic features. This includes hyperactivity, inattention, repetitive thoughts and
behavior, self-injurious behavior, and aggression.

Stimulants are contraindicated those with ASD due to increased irritability and
stereotypic movements, unless they display significant symptoms associated with ADHD.
BEHAVIORAL INTERVENTIONS
DISCRETE TRIAL TRAINING (DTT)

DTT is a method of teaching in which the instructor/clinician uses directed, massed trial
instruction, with reinforcers chosen for strength, and clear contingencies and repetition to
teach new skills.

Falls under ABA.

BEHAVIORAL INTERVENTIONS
DISCRETE TRIAL TRAINING (DTT) STEPS

1. Decide what to teach.

2. Break down skill into teachable steps.
3. Set up data-collection / tracking system
1. May be a simple worksheet or other form of observation
4. Designate Location
1. DTT for ASD is usually done in a naturalistic environment (home, school).
5. Gather Materials
6. Deliver Trials
7. Massed Trial Teaching
8. Conduct Discrimination Training
9. Review and Modify
DISCRETE TRIAL TRAINING (3:40)
BEHAVIORAL INTERVENTIONS
Early Intensive Behavioral Intervention (EIBI)

EIBI is a comprehensive ABA program designed to target a broad range of skills critical
to early childhood development. EIBI has been endorsed as well-established and
efficacious by the APA and is the only intervention endorsed by the Surgeon General.

The purpose of EIBI is to increase intellectual (communication, cognitive, and academic)

skills and adaptive functioning (social, self care) skills and to decrease the core ASD
symptoms and deficits.

EIBI’s seeks to ultimately establish children in typical home and school environments
where minimal support is required.
BEHAVIORAL INTERVENTIONS
Early Intensive Behavioral Intervention (EIBI)

Many forms of EIBI exist (eg, Lovaas). However, they all share three (3) components.

1. Intensive treatment delivery

(30-40 hours/week)

2. Hierarchially organized curriculum that focuses on:

Learning Readiness
Communication
Social and pre-academic repertoires

3. Teaching methods based on Operant Conditioning.

BEHAVIORAL INTERVENTIONS
Lovaas Approach

Form of EIBI utilizing ABA

Highly Structured
Relies on Discrete Trial Training
Uses extinction to reduce stereotypical autistic behaviors and provisions socially
acceptable alternatives to self-stimulatory behaviors.

Treatment can begin at 3 years-of-age.

Ideally is performed 5-7 days a week, with 35-40 hours per week total.
Sessions are designed to conclude upon child’s loss of focus.

Year 1: Reduce Self-Stimulation, “Normal” Toy play, and family integration into Treatment
Year 2: Expressive and Abstract language skills, peer interaction, basic socialization.
Year 3: Emotional Expression and academic skills.
WHAT DOES LOVAAS METHOD LOOK
LIKE?

Therapists work in the patient’s home, school, and/or community for an average of 40 hours
Per week.

Parents are extensively trained in the treatment procedures to so that treatment can be
Near continuous in naturalistic settings (Generalizability).
MORE ON LOVAAS
• Originally criticized for use of aversives (shock, shouting, slapping) as punishment.
• Aversives are no longer used.

• Expensive (Approx $20k / Year on Average)

• May be covered under Free and Appropriate Public Education

• When compared to 18 years of special education classes (TAU), research has

shown that DTT/ABA/Lovaas interventions would save $208,000 per child.

• Replicated:

• Cohen, Amerine-Dickens, & Smith, 2006

• Howard, Sparkman, Cohen, Green, & Stanislaw, 2005
• Reichow & Woolery, 2009
• Sallows & Graupner, 2005

• Lovass method meets Chambless and colleagues requirements for “Well-established”.

BEHAVIORAL INTERVENTIONS
Pivotal Response Training (PRT)

PRT targets child motivation, responsivity to multiple cues, self-management, and social
initiations.

These areas are targeted due to their foundational nature. By improving the target
domains, widespread, collateral improvements in communication, social, and
behavioral domains can be achieved.
BEHAVIORAL INTERVENTIONS
Pivotal Response Training (PRT)

PRT involves more of the following over DTT:

Child Choice
(Reinforcers, Activities)
Mixture of Tasks

PRT is also more “play based” in that it feels less structured than DTT to the child.
BEHAVIORAL INTERVENTIONS
Verbal Behavior Intervention (VBI)

Form of ABA that teaches communication based upon operant conditioning.

Teaches the student why we use words, rather than words themselves.

Verbal Behavior Therapy focuses on four word types. They are:

Mand. A request. Example: “Cookie,” to ask for a cookie.

Tact. A comment used to share an experience or draw attention. Example: “airplane” to

point out an airplane.

Intraverbal. A word used to answer a question or otherwise respond. Example: Where do

you go to school? “Castle Park Elementary.”

Echoic. A repeated, or echoed, word. Example: "Cookie?" “Cookie!” (important as the

student needs to imitate to learn)
0:21
QUANTITATIVE RESEARCH
META ANALYSIS OF EIBI FOR CHILDREN WITH AUTISM
Eldevik, Hastings, Hughes, Jahr, Eikeseth, & Cross, 2009

Results for EIBI:

Overall g (IQ): 1.10

Overall g (ABC): .66

Large and Moderate

PREDICTING TREATMENT RESPONDERS
Children with more toy play, less social avoidance, and more stereotypical language
Make the most gains from treatment. (Sherer & Schreibman, 2005)

Pre-treatment imitation also predicts social outcomes.

The above are indicators of severity.

The identification of mediators and moderators represent a great need for early intervention
Research specific to ASD.
PSYCHOPHARMOCOLOGY
Risperidone (Risperdal) has been FDA approved for
treating irritability in children with ASD who are
between 5-16 years of age.

The only FDA approved medication for ASD.

Atypical Antipsychotic
Dopanine antagonist with anti-serotonergic, anti-
adrenergic, and anti-histaminergic promperties.

Traditionally used as an antipsychotic to treat

Schizophrenia and Bipolar Disorder.
PSYCHOPHARMACOLOGY
Risperidone (Risperdal) side effects:
Aggressive behavior
agitation
anxiety
changes in vision, including blurred
vision
difficulty concentrating
difficulty speaking or swallowing
inability to move the eyes
increase in amount of urine
loss of balance control
mask-like face
memory problems
muscle spasms of the face, neck, and
back
problems with urination
restlessness or need to keep moving
(severe)
shuffling walk
skin rash or itching
stiffness or weakness of the arms or legs
tic-like or twitching movements
trembling and shaking of the fingers
and hands
trouble sleeping
twisting body movements
weight gain
PSYCHOPHARMOCOLOGY
Other Medications used to treat peripheral ASD
symptoms:

SSRIs: May reduce frequency and intensity of repetitive

behaviors, decrease anxiety, irritability, and aggressive
behavior.

Stimulants: May increase focus and decrease

hyperactivity in those with mild ASD symptoms.

Anti-convulsants: Used to treat seizure disorders such as

epilepsy. (1/3 of those with ASD have seizures or seizure
disorders).
WHAT INTERVENTIONS ARE PARENTS
ACTUALLY USING?