treatment section of the Autism Spectrum Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The goal of intervention is to improve social communication and other language impairments and modify behaviors to improve an individual's quality of life and increase social acceptance. Essential outcomes focus on improvements in social communication that affect the individual's ability to develop relationships, function effectively, and actively participate in everyday life. SLPs often collaborate with other professionals on the individual's team in designing and implementing effective treatment plans. See
sample intervention goals associated with core challenges [PDF].
Given the nature of autism and the needs of individuals with ASD, families often become teachers and interventionists. Most comprehensive programs for individuals with autism offer parents/caregiver training. SLPs establish ongoing partnerships with families to develop meaningful learning opportunities, provide information, teach strategies, and offer feedback. Clinicians need to recognize and integrate goals that embrace the family's cultural and linguistic communication values and preferences. See
Individuals with ASD have unique needs with respect to learning independence and self-advocacy due to their core challenges in social interaction and verbal and nonverbal communication. SLPs can contribute to the independence and self-advocacy of individuals with ASD by ensuring each individual has a functional communication system (including AAC) and by supporting communication in different social settings with a variety of partners to promote generalization of skills.
Treatment for individuals with ASD typically includes
- setting goals based on assessment data that target the core deficits in ASD and focus on initiating spontaneous communication in functional activities, engaging in reciprocal communication interactions, and generalizing gains across activities, environments, and communication partners;
- using a multimodal communication system (e.g., spoken language, gestures, sign language, picture communication, speech-generating devices [SGDs], and/or written language) that is individualized according to the individual's abilities and the contexts of communication;
- considering family priorities when selecting intervention goals—meaningful outcomes are strongly correlated with communication competence across functional social contexts (e.g., home, school, vocational, and community settings);
- incorporating cultural, linguistic, and personal values and attributes unique to each individual into therapeutic activities;
- using a range of approaches for enhancing communication skills along a continuum from behavioral to developmental;
- using developmental sequences and processes of language development to provide a framework for determining baselines and implications for intervention goals;
- measuring progress using systematic methods to determine whether an individual with ASD is benefiting from a particular treatment program or strategy.
Core challenges of ASD take different forms as an individual responds to intervention and progresses through developmental stages from prelinguistic to emerging language and advanced language stages. (See
sample intervention goals associated with core challenges [PDF].) Actual goals will vary based on those aspects of development that are consistent with family priorities and with the individual's functional needs within his or her current social contexts.
A number of treatment modes/modalities and options are described below. When selecting a treatment mode/modality or option, the SLP matches the treatment with the intervention goals and priorities appropriate for the individual's developmental stage. For example, a treatment that is evidence-based for an individual at the emerging language stage may not be evidence-based for an individual at the prelinguistic stage.
Treatment modes and modalities are technologies or other support systems that can be used in conjunction with or in the implementation of various treatment options. For example, video-based instruction can be used in peer-mediated interventions to address social skills and other target behaviors.
Augmentative and Alternative Communication (AAC)
AAC involves supplementing or replacing natural speech and/or writing with aided (e.g., Picture Exchange Communication System [PECS], line drawings, Blissymbols, speech generating devices, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. Whereas aided symbols require some type of transmission device, production of unaided symbols only requires body movements. For more information on speech-generating devices for children with autism, see van der Meer and Rispoli (2010). For more information about AAC, see ASHA's Practice Portal page on Augmentative and Alternative Communication.
Activity Schedules/Visual Supports
Activity schedules/visual supports include objects, photographs, drawings, or written words that act as cues or prompts to help individuals complete a sequence of tasks/activities, attend to tasks, transition from one task to another, or behave appropriately in various settings. Written and/or visual prompts that initiate or sustain interaction are called scripts. Scripts are often used to promote social interaction, but can also be used in a classroom setting to facilitate academic interactions and promote academic engagement (Hart & Whalon, 2008).
Computer-based instruction involves the use of computer technology (e.g., iPADs) and/or computerized programs for teaching language skills, including vocabulary, social skills, social understanding, and social problem solving.
Facilitated communication is a technique by which a "facilitator" provides physical and other supports in an attempt to assist a person with a significant communication disability to point to pictures, objects, printed letters, and words or to a keyboard and thereby communicate. Supporters of this technique believe that its use can reveal previously undetected literacy and communication skills in persons with autism and other disabilities.
According to ASHA's position statement titled
Facilitated Communication, "It is the position of the American Speech-Language Hearing Association (ASHA) that the scientific validity and reliability of facilitated communication have not been demonstrated to date. Information obtained through or based on facilitated communication should not form the sole basis for making any diagnostic or treatment decisions." (ASHA 1995, para.2)
Video-based instruction (also called video modeling) is an observational mode of teaching that uses video recordings to provide a model of the target behavior or skill. Video recordings of desired behaviors are observed and then imitated by the individual. The learner's self-modeling can be videotaped for later review.
There are many different intervention approaches and strategies for individuals with ASD. Programs differ in the method used to address goals; approaches range from discrete trial, traditional behavioral therapies to social-pragmatic, developmental therapies (Prizant & Wetherby, 1998). Programs also differ in how goals are prioritized and addressed; focused interventions rely heavily on individual strategies, used alone or in combination, to target specific skills or behaviors (e.g., to increase verbalization), while comprehensive interventions involve multiple treatment strategies/treatment packages to target a broad range of skills or behaviors (e.g., to enhance learning).
SLPs and educators determine which methods and strategies are effective for a particular student/client by taking into consideration the individual's level of social and linguistic development, cultural background and values, personal preferences, family resources, learning style, behavior repertoire, and communication needs.
Below are brief descriptions of both general and specific treatments for addressing ASD. Some attempt has been made to organize treatment options into broader categories, recognizing that several approaches have components of more than one broader category (e.g., the Early Start Denver model combines developmental approaches with behavioral teaching strategies).
This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA. For a more comprehensive list of treatment options, see the
Treatment Approaches section of the Autism Spectrum Disorders Evidence Map.
Auditory/Sensory Integration Training
Broadly speaking, sensory integration therapies are used to treat integration dysfunction in one or more sensory systems. Treatments can include physical exercise, sensory/tactile stimulation, and auditory integration training. Auditory integration therapy (e.g., the Berard method) involves exercising the middle ear muscles and auditory nervous system to treat distortions/dysfunctions of the auditory system (Berard, 1993).
According to ASHA's position statement titled,
Auditory Integration Training, "The 2002 ASHA Work Group on AIT, after reviewing empirical research in the area to date, concludes that AIT has not met scientific standards for efficacy that would justify its practice by audiologists and speech-language pathologists" (ASHA, 2004, para. 1).
Behavioral interventions and techniques are designed to reduce problem behaviors and teach functional alternative behaviors using the basic principles of behavior change. These methods are based on behavioral/operant principles of learning; they involve examining the antecedents that elicit a certain behavior, along with the consequences that follow that behavior, and then making adjustments in this chain to increase desired behaviors and/or decrease inappropriate ones.
Behavioral interventions range from one-to-one discrete trial instruction to naturalistic approaches that focus only on communication, on communication as well as other aspects of educational programming, or on replacing maladaptive behaviors that are being used for communication.
Examples of behavioral interventions include the following:
Applied Behavior Analysis (ABA)—a treatment approach that utilizes principles of learning theory to bring about meaningful and positive change in behavior. ABA techniques have been developed for individuals with autism to help build a variety of skills (e.g., communication, social skills, self-control, and self-monitoring) and help generalize these skills to other situations. The techniques can be used in both structured (e.g., classroom) and everyday (e.g., family dinnertime) settings and in one-on-one or group instruction.
Intervention is customized, based on the individual's needs, interests, and family situation. ABA techniques are often used in intensive, early intervention (below age 4 years) programs to address a full range of life skills. Intensive programs total from 25 to 40 hours per week for 1 to 3 years. Qualifications for providing ABA therapy to individuals with autism may vary by state; check with your state, as this may have an impact on reimbursement.
Discrete Trial Training (DTT)—a one-to-one instructional approach utilizing behavioral methods to teach skills in small, incremental steps in a systematic, controlled fashion. The teaching opportunity is a discrete trial with a clearly identified antecedent and consequence (e.g., reinforcement in the form of praise or tangible rewards) for desired behaviors. DTT is most often used for skills that learners are not initiating on their own, have a clear, correct procedure, and can be taught in a one-to-one setting.
Functional Communication Training (FCT)—a behavioral intervention program that combines the assessment of the communicative functions of maladaptive behavior with ABA procedures to teach alternative responses. Problem behaviors can be eliminated through extinction and replaced with alternate, more appropriate forms of communicating needs or wants. FCT can be used with children with ASD across a range of ages and regardless of cognitive level or expressive communication abilities (Carr & Durand, 1985).]
Incidental Teaching—a teaching technique that utilizes behavioral procedures; naturally occurring teaching opportunities are provided, based on the child's interests. Following the child's lead, attempts to communicate are reinforced as these attempts get closer to the desired communication behavior (McGee, Morrier, & Daly, 1999)
Milieu Therapy—a range of methods (including incidental teaching) that are integrated into a child's natural environment. It includes training in everyday environments and during activities that take place throughout the day, rather than only at "therapy time" (Kaiser, Yoder, & Keetz, 1992).
Pivotal Response Treatment (PRT)—a play-based, child-initiated behavioral treatment. Formerly referred to as Natural Language Paradigm (NLP), PRT has as its goals to teach language, decrease disruptive behaviors, and increase social, communication, and academic skills. Rather than target specific behaviors, PRT targets pivotal areas of development (response to multiple cues, motivation, self-regulation, and initiation of social interactions) that are central to—and result in improvements across—a wide range of skills (Koegel & Koegel, 2006). PRT emphasizes natural reinforcement (e.g., the child is rewarded with an item when a meaningful attempt is made to request that item).
Positive Behavior Support (PBS)—uses functional assessment of problem behaviors to target the relationship between challenging behavior and communication. It integrates principles of applied behavior analysis with person-centered values to foster skills that replace challenging behaviors. The clinician carefully analyzes the functions of the behavior(s) and develops and implements prevention strategies (i.e., antecedent packages) to foster the client's successful use of replacement skills to produce positive response in social interactions. PBS can be used to support children and adults with autism who demonstrate problem behaviors (Carr et al., 2002).
Self-Management—an approach that involves interventions aimed at helping individuals learn to independently regulate their behaviors and behave appropriately in a variety of contexts. Individuals learn to tell the difference between appropriate and inappropriate behaviors, monitor and record their behaviors, and reward themselves for using appropriate behaviors. Self-management interventions can be used across a wide range of ages from early childhood through adulthood.
Time Delay—a behavioral method of teaching that fades the use of prompts during instruction. For example, the time delay between initial instruction and any additional instruction or prompting is gradually increased as the individual becomes more proficient at the skill being taught. Time delay can be used with individuals regardless of cognitive level or expressive communication abilities.
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) is an intervention approach that combines cognitive and behavioral learning principles to shape and encourage desired behaviors. The underlying assumptions of CBT are that an individual's behavior is mediated by maladaptive patterns of thought or understanding and that change in thinking or cognitive patterns can lead to changes in behavior. CBT is used primarily to help individuals with ASD improve behavior by learning to regulate emotions and control impulses. Examples of programs/approaches that incorporate CBT principles include the following.
Exploring Feelings—a structured cognitive behavior therapy program designed to encourage the cognitive control of emotions (anxiety and anger). Sessions include activities to explore specific feelings (e.g., being happy, relaxed, anxious or angry). A follow-up implementation project is completed by the child prior to the next session. The Explore Feelings program was designed for small groups of children between the ages of 9 and 12, but it can be modified for use with only one child (Attwood, 2004).
Rational Emotive Behavioral Therapy—a therapy approach that focuses on helping the individual acknowledge the problems that are upsetting him/her, accept emotional responsibility for these problems, and be empowered to change. The ultimate goal is to be able to lead a happier, more fulfilling life (Ellis & Dryden, 1997).
Social Thinking®—a cognitive-based treatment framework for preschool and school-age children and adults with social learning challenges (including ASD, social communication disorder, and other related diagnoses). It comprises strategies to target pragmatic language, social emotional learning, perspective taking, and social skills. The framework, based in CBT, teaches individuals to understand the "thinking" underlying the production (Lee et al., 2009; Winner & Crooke, 2009, 2011).
The Denver Model is a child-led, play-based treatment approach that focuses on the development of social communication skills through intensive one-on-one therapy, peer interactions in the school setting, and home-based teaching (Rogers & Dawson, 2009). The Early Start Denver Model for toddlers is an extension of the Denver Model; it combines developmental approaches with behavioral teaching strategies and can be delivered in a variety of settings (e.g., by the therapist and/or parents in group or individual sessions in the clinic or at home).
Gentle Teaching is a framework for serving individuals with special needs that focuses on providing companionship and open, loving support and guidance. Gentle teaching uses the relationship between the individual and his/her caregiver as the foundation for teaching. The aim is to develop a safe and loving environment in which the individual can develop talents and reach his/her full potential. This approach eliminates punishment as a way to control behavior; it includes errorless learning, choice making, and fading prompts (Jones & McCaughey, 1992; McGee, 1990).
Literacy intervention approaches incorporate a variety of instructional strategies to improve word decoding, word identification, reading fluency, reading vocabulary, and reading comprehension across a variety of materials and in a number of contexts. Depending on the student's skill level, instructional strategies might include engaging in shared book reading, teaching literacy in natural contexts, labeling objects/pictures to promote sight word reading, reading and writing about personal experiences, promoting phonological awareness, and teaching the student how to monitor comprehension while reading. For a review of strategies for promoting literacy, see Lanter and Watson (2008).
Parent-mediated or implemented intervention consists of parents' using direct, individualized intervention practices with their child to increase positive learning opportunities and acquisition of skills.
More Than Words—a Hanen Program® that offers a parent-directed approach focusing on day-to-day life, taking advantage of everyday activities to help the child improve communication and social skills (Sussman, 1999). This program is typically used for early language intervention with young children with ASD.
Talkability™—a Hanen Program® for parents of verbal children with ASD. The program teaches parents practical ways to help their child learn people skills, such as "tuning in" to the feelings and thoughts of others by attending to nonverbal cues, such as body language, facial expressions, and tone of voice. The ability to consider the point of view of others and have empathy are considered essential for successful conversation and for making friends (Sussman, 2006).
Son-Rise—a child-centered, parent-directed, and relationship-based approach, based on the view that autism is a social connecting disorder (Kaufman, 1995). Parents and facilitators join in the child's repetitive behaviors until the child demonstrates a willingness to engage in play; more complex social interactions are then encouraged in a nonthreatening way. The Son-Rise program is used with children and adults with ASD and other developmental difficulties.
Peer-mediated or implemented treatment approaches incorporate peers as communication partners for children with ASD in an effort to minimize isolation, provide effective role models, and boost communication competence. Typically developing peers are taught strategies to facilitate play and social interactions; interventions are commonly carried out in inclusive settings where play with typically developing peers naturally occurs (e.g., preschool setting).
LEAP—a multi-faceted program for preschool children with ASD (Hoyson, Jamieson, & Strain, 1984). LEAP utilizes a variety of strategies and methods, including ABA, peer-mediated instruction, self-management training, prompting, and parent training. LEAP is implemented in a classroom setting consisting of children with ASD and typically developing peers and designed to support child-directed play.
Circle Of Friends—a treatment approach that uses the classroom peer group to improve the social acceptance of a classmate with special needs by setting up a special group or "circle" of friends. The focus is on building behaviors that are valued in everyday settings. The application of skills to new and appropriate situations is reinforced as naturally as possible as they occur (Whitaker, Barratt, Joy, Potter, & Thomas, 1998).
Integrated Play Groups—a therapy model designed to support children of different ages and abilities with ASD in mutually enjoyed play experiences with typical peers and siblings. Small groups of children play together under the guidance of an adult facilitator. The focus is on maximizing the child's potential and his/her intrinsic desire to socialize with peers (Wolfberg & Schuler, 1993).
SCERTS—social communication (SC), emotional regulation (ER), and transactional support (TS)—is a comprehensive framework for targeting critical intervention goals relevant to the individual's stage of social, emotional, and communication development. The supports integrated into this framework fall under the transactional support process and are focused on enabling families, service providers, and members of the community to effectively implement evidenced-based teaching strategies in "real world" activities. The SCERTS Model is a comprehensive educational approach used with children of various ages, from preschool through school age (Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006).
Social Communication Interventions
Social communication treatment approaches and frameworks are designed to increase social skills, using social group settings and other platforms to teach peer interaction skills and promote socially appropriate behaviors and communication. There continues to be research in the development of social communication treatment approaches (Adams et al., 2012). The following is not an exhaustive list; SLPs are encouraged to research additional social communication treatment programs and approaches.
JASPER (Joint Attention Symbolic Play Engagement Regulation)—a treatment approach that combines developmental and behavioral principles. This approach targets the foundations of social communication (joint attention, imitation, play) and uses naturalistic strategies to increase the rate and complexity of social communication. The approach incorporates parents and teachers into implementation of intervention to promote generalization across settings and activities and to ensure maintenance over time (Kasari, Paparella, Freeman, & Jahromi, 2008).
Score Skills Strategy—a social skills program that takes place in a cooperative small group and focuses on five social skills: (S) share ideas, (C) compliment others, (O) offer help or encouragement, (R) recommend changes nicely, and (E) exercise self-control (Vernon, Schumaker, & Deshler, 1996).
Social Scripts—a prompting strategy used to teach children to use a variety of language skills during social interactions. Scripted prompts (visual and or verbal) are gradually faded out as children use new language skills more spontaneously (Nelson, 1978).
Social Skills Groups—groups in which appropriate ways of interacting with typically developing peers are taught through direct instruction, role-playing, and feedback. Groups typically consist of two to eight individuals with social communication disorders and a teacher or adult facilitator.
Social Stories™—a highly structured intervention that uses stories to explain social situations to children and to help them learn socially appropriate behaviors and responses (Gray et al., 2002).
Relationship-based practices in early intervention are aimed at supporting parent-child relationships (Edelman, 2004; Gutstein, Burgess, & Montfort, 2007).
Greenspan/Dir/Floortime—a model that promotes development by encouraging children to interact with parents and others through play. The model focuses on following the child's lead; challenging the child to be creative and spontaneous; and involving the child's senses, motor skills, and emotions (Greenspan, Weider, & Simons, 1998).
Project Data (Developmentally Appropriate Treatment For Autism)—a model for developing, implementing, evaluating, and disseminating a program for young children with autism and their families. The project emphasizes best practice from early childhood special education combined with applied behavioral analysis to develop intervention strategies for the classroom and community settings (Center on Human Development and Disability, n.d.).
Relationship Development Intervention® (RDI)—a family-based, behavioral treatment designed to address the core symptoms of autism. It is based on the theory that dynamic intelligence (the ability to think flexibly) is the key to improving the quality of life for individuals with ASD. RDI helps individuals form personal relationships by strengthening the building blocks of social connections, including the ability to form emotional bonds and share experiences. Parents, teachers, and other caregivers can be involved in the implementation of RDI (Gutstein & Gutstein, 2009).
TEACCH (Treatment and Education of Autistic and Related Communication Handicapped Children) is a university-based system of community regional centers that provides clinical services, such as diagnostic evaluations, parent training and parent support groups, social play and recreation groups, individual counseling, and supported employment (Mesibov, Shea, & Schopler, 2007). TEACCH combines developmentally appropriate practice with behavioral techniques (e.g., environmental control/structure) and family collaboration and involvement.
The transition from adolescence to young adulthood can be challenging for individuals with or without disabilities. The core challenges associated with ASD can present added challenges to success in post-secondary educational programs, employment,maintaining relationships, and acquiring the skills necessary for independent living (Howlin & Moss, 2012; Zager & Alpern, 2010). These findings highlight the need for continued support to facilitate a successful transition to adulthood. SLPs are involved in transition planning and may be involved to varying degrees in other support services beyond high school.
Support for transitioning individuals with ASD includes, but is not limited to, the following.
Transition Planning—the development of a formal plan during the transition year of high school that includes identifying career goals and educational needs; providing career counseling and opportunities for work experiences; and providing training in communication skills unique to academic, employment, and community settings. Effective transition planning involves the student as an active, respected participant of the team (Wehman, 2006) as well as his/her family, who can provide valuable information about the student's needs.
Disability Support Services—individualized support for college-level students that can include academic accommodations if needed and social communication supports (e.g., counseling, support groups).
Vocational Support Services—including assessments to identify vocational strengths, career counseling, training in social skills for the workplace, vocational training, résumé preparation, interview practice, job search and job placement, and on-the-job supports such as reasonable workplace modifications and job coaching (Hendricks, 2010; Van Bourgondien & Woods, 1992)
Housing—including transition from the family home to a group home, semi-independent residence, or independent living environment (Lawrence, Alleckson, & Bjorklund, 2010). Residential settings are often small, community-based settings designed to support independence, community living skills, and continued collaboration between persons with autism and their family members, residential staff, case managers, SLPs, job coaches, etc.
Community Integration—providing opportunities for social involvement and the development of friendships. A peer mentor can serve as a role model and source of social skills information and feedback in these settings (Lawrence, Alleckson, & Bjorklund, 2010).
service delivery section of the Autism Spectrum Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of speech and language treatment that is optimal for children with social communication disorders, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may impact treatment outcomes.
- Format: whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group
- Provider: the person providing treatment (e.g., SLP, trained volunteer, caregiver)
- Dosage: the frequency, intensity, and duration of service
- Timing: the timing of intervention relative to the diagnosis
- Setting: the location of treatment (e.g., home, community-based, school)
Learning in natural learning environments appears to be the most effective intervention approach. Not only do such environments invite higher rates of initiation and generalization, they also enhance the ecological validity of the intervention (NRC, 2001).