Review of the Research to Identify the Most Effective Models of Practice in Early Intervention for Children with Autism Spectrum Disorders


Appendix F: Application of principles of good practice to interventions



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Appendix F: Application of principles of good practice to interventions

Consideration of the extent to which intervention reflects principles of good practice for early intervention and for autism early intervention

Principles of good practice


This section addresses two areas:


good practice guidelines that are common to most generic early intervention, education or therapy based services

key elements of effective interventions that are specific to autism and drawn from the current literature on autism spectrum disorders.


Good Practice Guidelines


There are a number of basic, good practice principles that are fundamental to working with young children and their families. It would be anticipated that services on the provider panel would be able to demonstrate their adherence to the majority of the following:


Individualised Assessment for Intervention Planning: This refers to assessments carried out with individual children to determine their strengths and needs in a range of core autism areas, such as communication and social interaction, along with developmental skills. This assessment guides the content of intervention while providing information about the best techniques to use with an individual child. The process should not be confused with assessment for diagnosis of autism. Assessment for intervention planning may take a range of forms including parent questionnaires, formal assessments or structured observations in play.

Individualised programming based on strengths and needs: Programming for intervention should be individualised and based on the findings of the intervention planning assessment. Programs should be designed to address the child’s needs while acknowledging, drawing on and encouraging their areas of strength and talent.

Individual Plan (IP): Individual Plans (IP) go by many names, including Individual Education Plans (IEP), Individual Family Service Plan (IFSP), Personal Plans (PP), Individual Service Plans (ISP). For simplicity, the term ‘Individual Plan’ (IP) will be used in this document to refer to these plans. The basic goals of an Individual Plan are to document:


    • the child’s areas of strengths and needs

    • goals for intervention, identified through a collaborative process with those involved with the child , including the family

    • information about how these goals will be addressed

All children in early intervention services should have an IP that is developed by all those involved with the child, including family, early intervention providers, preschools or childcare services. IPs should be developed at least annually and reviewed at least every 6 months.

Review, evaluation and adjustment of program: Intervention programs need to be evaluated regularly to ensure that they continue to meet the needs of the child. This process involves a review of the IP goals, review of the child’s skills and needs to ensure that the program is addressing skills and needs, i.e., the child is showing improvement and the goals are still relevant and development of revised and if required new goals, as appropriate, and in collaboration with the family and other key people in the child’s life.

Collaboration with other professionals: The importance of multidisciplinary and/or trans disciplinary teams to early intervention for children with autism is described in full in the following section.

Family centred practice: The importance of family centred practice is described in Section 1.

Key elements of effective interventions for children with autism

Program Content

Within this element there are five basic skill domains; ability to attend to elements of the environment, ability to imitate others, ability to comprehend and use language, ability to play appropriately with toys (Howlin 1997), and ability to socially interact with others (Dawson & Osterling 1997). Marcus, Garfinkle and Wolery (2001) suggested that effective programs utilise the following intervention strategies based on the learning characteristics of children with autism:



clarifying meaningful information, organisation and scheduling

teaching across settings and people

active directed instruction

individualisation of teaching materials and curriculum

provision of visual supports

teaching imitation at a developmentally appropriate level

using strengths and interests to help with weak areas of development.
The service should address one or more of the key features of autism spectrum disorders:


communication

social interaction

repetitive behaviour and/or restricted interests.


Associated features of autism can include:


consideration of sensory processing difficulties (though this is not adequately addressed via sensory integration therapy or multi-sensory rooms)

anxiety


intellectual disability/learning difficulties.
Questions to ask include:


Which of the key features does this intervention address?

Which of the associated features does this intervention address?

How does the intervention cater to the learning characteristics of children with an ASD, including need for organisation and scheduling, teaching across settings and people, individualisation of teaching materials and curriculum, use of visual supports and using strengths and interests?
Highly Supportive Teaching Environments and Generalisation Strategies

The core skills outlined above are taught in a highly supportive teaching environment and are then systematically generalised to more complex, natural environments. Howlin (1997) stressed the need for behaviourally oriented strategies. Highly supportive teaching environments utilise appropriate environmental supports, structured teaching, visual supports and systematically help children to generalise content of the intervention to other settings (e.g. parent training and information, sharing information with childcare providers, providing services outside traditional clinic based settings). It is also important to consider staffing ratios, especially in group interventions. Implementation of individual child goals in a small group context is not feasible with a less than 2 adults for 6 children.

The interventions provided should include an appropriate staff to child ratio (no more than 6 children with 2 staff). Service providers should be able to describe how they systematically help children to generalise content of the intervention to other settings (e.g. parent training and information, sharing information with childcare providers, providing services outside traditional clinic based settings).

Questions to ask include:


What is the staff to child ratio for group programs?

How do you ensure that skills taught in one setting are generalised to the home and community settings?


Predictability and Routine


Research shows that children with autism become more socially responsive and attentive when information is provided in a highly predictable manner and, conversely, that their behaviour is severely disruptive when the same stimuli are presented in an unpredictable manner. Service providers can address this area by establishing routines within sessions supported visually where appropriate and by supporting families and other settings to maximise the use of visually supported routines, social interactions, communication and behaviour strategies.

Service providers should address the need for predictability and routine by establishing routines within sessions supported visually where appropriate and by supporting families and other settings to maximise the use of visually supported routines, social interactions, communication and behaviour strategies.

Questions to ask include:


How is predictability and routine supported during sessions?

How are parents and other carers supported to establish routines and predictability in other settings?


A Functional Approach to Challenging Behaviours

Most programs focus on the prevention of problem behaviour by means of increasing the child's interest and motivation, structuring the environment and increasing positive reinforcement for appropriate behaviour. Should the problem behaviour persist despite ecological management, the behaviour is analysed to determine the function of the behaviour for the child. The environment is then adapted in specific ways to avoid triggers and reinforcers for the problem behaviour and appropriate behaviour is taught to give the child an alternative more acceptable behaviour. Howlin (1997) stressed the importance of recognising the communicative function of problem behaviour and the need to teach the child more appropriate alternative means of communication. Punitive measures, such as exclusionary time out, withdrawal of privileges and other forms of punishment are not appropriate behaviour support techniques for children with autism.

Service providers should use a functional approach to challenging behaviours, including ecological management and analysis to determine the communicative function of the behaviour and teaching appropriate alternative behaviours. Punitive measures, such as exclusionary time out, withdrawal of privileges and other forms of punishment are not appropriate behaviour support techniques for children with autism. Obsessions and rituals may be an underlying function of some challenging behaviours, however these behaviours may have a positive function for the child in regulating anxiety and may also act as a powerful source of motivation and reward.

Questions to ask include:


How are challenging behaviours addressed during intervention sessions?

What methods are used to support parents and other carers to prevent challenging behaviours and to support alternative appropriate behaviours?

How are obsessions and rituals addressed?
Transition Support


Most programs recognise that transition to school is a time when children with autism need a great deal of support. Effective programs actively teach school skills to enable the child to be as independent as possible. Programs frequently take an active role in finding school placements that will best suit the child and then actively integrate the child with autism into the new setting. Transition supports for children with autism can include assisting the child to learn appropriate school readiness skills, collaboration and communication with new settings (e.g. schools) about the child’s current skills and needs, and actively supporting transition to a new environment through visits, visual supports and stories where appropriate.

Service providers should adequately address transition where appropriate. Transition supports for children with autism can include assisting the child to learn appropriate school readiness skills, collaboration and communication with new settings (e.g. schools) about the child’s current skills and needs, and actively supporting transition to a new environment through visits, visual supports and stories where appropriate.

Questions to ask include:


How does the service support transitions to new settings? Family Involvement

Effective programs recognise that parents are a critical component in early intervention for children with autism. Most programs support parents to choose the type and intensity of their involvement in their child's program. Effective programs are sensitive to the stresses encountered by families of children with autism and provide parent groups and other types of emotional support (e.g. Dawson & Osterling, 1997; Tonge & Brereton, 2005). Families should also be supported to utilise strategies taught as part of the interventions at home and to be empowered to encourage their children’s communication, social interaction and to manage behaviour effectively at home and in the community.

Service providers should utilise a family centred practice approach wherever appropriate and that families are as fully engaged in decision making, goal setting, planning and implementing strategies as possible.

Questions to ask include:



How does the service ensure families are involved in assessment, planning, goal setting and strategy implementation for their child?

How do services support parents to learn about autism and appropriate strategies?

How do services support families in times of stress?
Use of visual supports


Dawson and Osterling (1997) noted that the provision of augmentative communication methods is a characteristic of many programs reviewed. In addition, both Howlin (1997) and Quill (1997) stressed the importance of visually cued instruction to provide the child with a predictable and readily understood environment.

Services should use highly supportive teaching strategies and supporting predictability and routine during intervention settings and that these strategies are also encouraged and supported in other environments. One of these strategies is the use of visual supports and this should be encouraged in most settings.

Questions to ask include:


What strategies are used to provide a supportive teaching environment and to encourage predictability and routine?

What role do visual supports play?


Multi-disciplinary collaborative approach

Autism requires a multi-disciplinary approach to assessment and service provision (Jordan, 2001). The team is likely to include speech pathologists, teachers, psychologists, occupational therapists and parents. Children with autism should access services that are multidisciplinary and collaborative (assessments and programs are provided by a number of individual service providers, such as speech pathologists or teachers, who communicate and collaborate with each other to develop goals, provide intervention and evaluate progress) or trans disciplinary (assessments and programs are holistic, developed by a team of professionals but delivered by a single provider working across disciplines). Collaborative multidisciplinary and trans disciplinary approaches ensure that all areas of need seen in children with autism can be adequately addressed.

HCWA Early Intervention assistance funding is recommended for services that are multidisciplinary and collaborative (programs are provided by a number of individual service providers, such as speech pathologists or teachers, who communicate and collaborate with each other to develop goals, provide intervention and evaluate progress) or trans disciplinary (programs are holistic, developed by a team of professionals but delivered by a single provider working across disciplines). Collaborative multidisciplinary and trans disciplinary approaches ensure that all areas of need seen in children with autism can be adequately addressed.

Questions to ask include:


Which disciplines (SP, educator, OT, psychologist) are directly involved in service provision for individual children?

If the service is a single discipline service, how are collaborative links made with other disciplines providing services for the child?


Additional elements


In addition to the elements listed above, a high level of intensity is recommended (see page 3).

Interventions reflecting good practice are also characterised by the following:




inclusion of typically developing peers

promotion of independent functioning throughout the intervention programs

incorporation of obsessions and rituals as part of structured teaching and positive behaviour support.





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