Moving Toward a Multi-Treatment to Autism
The whole is greater than the sum of the parts
This article, published in The Autism File in January, 2009, describes how multi-treatment approaches use a set of therapies to address each of your child’s unique challenges in the right order and timing, so that your child receives the greatest benefit.Â
Read the article published by renowned autism specialist and author, Jonathan Alderson, Ed. M., to learn about the three principles that form a successful multi-treatment approach.
About Jonathan Alderson, Ed. M.
After completing his Masters of Education in Administration, Planning, and Social Policy at Harvard University, Jonathan has a private educational consulting practice in Toronto, Ontario working primarily as an autism treatment specialist training families with special needs children.
Combining experience as the Curriculum Specialist Coordinator with Teach For America in Houston, Texas, an internship with the Harvard Family Research Project, and as a coordinator of the Intensive Preparation for the Study of International Education (IPSIE) programme at the Harvard Graduate School of Education, Jonathanâs diverse education and work experience provides the inspiration for his focus on bringing innovation to the field of autism treatment.
Moving Toward a Multi-Treatment to Autism
The Autism File, January 2009
A young couple sits in a doctors office, both of them feel anxiety brewing in their stomachs. They had waited two months for this appointment. The doctor, from behind his desk confirms their worst fears; with a certain lack of emotion he confers a diagnosis of autism on their on their 3-year old son. After he negotiates their tears and shock, on the way out he hands them several brochures introducing them to local autism support centres. They have a thousand questions and no answers. At home, without even taking off their shoes or coats, they Google âAutismââŚover 20 million linksâŚwhere do they begin?
Sensory Integration therapies and the Defeat Autism Now (DAN!) protocol, socialization, Pamela Wolfburg and play-groups, Auditory Integration Therapy, Lovaas and Applied Behaviour Analysis (ABA), early intervention, home-based, school-based, residential care, TEACCH, Bostonâs Higashi School, special diets, promises of a cure, Vitamin B12, swimming with dolphins, acupuncture, play-therapies, The Son-Rise Program, Relationship Development Intervention, Floortime, physical therapy, music therapy, equestrian therapy, and Intensive Multi-Treatment Intervention (IMTI) could all possibly play a role: Where should they begin? What is best for their son? Six months later the couple is still spending most of their resources on researching treatments, reading recommended books, making phone calls to get on waiting lists, and feeling as confused and directionless as they had the first moment they heard the doctor say âautismâ.
The parents learn quickly that the diagnosis is multi-factorial: Social development delays, language delays, and stereotyped repetitious behaviours all impact a wide range of developmental steps. The symptoms manifest across a spectrum. Each child is uniquely complex. The young couple observes their own sonâs range of ability and disability. In their search for answers, they recognize parts of their child in othersâ anecdotes but never fully. As diverse as the explanations and theories of the causes of autism, we can agree that autism has a biological / physiological (body) component, a cognitive (mind) component, and a social / emotional (psychological) component, among others. Current research supports the idea that the factors contributing to the behaviour, communication and learning challenges of people on the autism spectrum are multifaceted; therefore, I believe, treatment should be multi-faceted as well. These days, most parents, professionals, books and reports agree. Yet, unfortunately, many current treatment models operate exclusive of other models and are uni-focused. In other words, treatments havenât been designed to address the multi-dimensional complexity of autism.
Each of the hundreds of treatments available may offer an important piece of âthe puzzleâ but it is parents who are left to piece the puzzle together. Which treatment âpiecesâ fit their childâs special gifts and challenges? How much of each different treatment should a child receive, and how should a family distribute their limited resources between the myriad choices? A family I recently guided through this decision process explained âWe heard about some great success stories about kids on special diets and supplements; weâll put all of our money in that direction if you think it will workâŚbut our doctor is pushing us to go ahead with the IBI training full-time if we can afford it. Weâre already stretched with finances and weâre hoping you can help us figure out what we should doâŚwe just want to do what is best for our son.â During my 16 years working in autism treatment, sadly this situation is the most common predicament in which parents find themselves. Itâs time the field moved toward more comprehensive and cooperative systems of treatment.
To add to the overwhelming number of choices a parent has to make, the field of autism is, more than other professional fields, I would argue, particularly proprietary: âOur method works, we have the answers, and others donâtâ. As families make their best effort to piece together a mix of treatments to address the many special needs of their child, a majority of therapists continue to believe their âuniqueâ method of treatment is the only real method of treatment and so the burden to choose is placed on the parents. Thousands of mothers of children with autism are left to do the impossible: to play the ultimate negotiator and diplomat communicator between competing therapists. The physical therapist strongly recommends that their child gets outside on the playground at least once a day, but the intensive behaviour therapist strongly recommends the child works indoors in 1-to-1 training for as many as 40 hours per week. Meanwhile, the local school principle and school psychologist are threatening that the child will suffer from lack of socialization if they are kept at home and not in school. Parents of children with autism are already challenged to function well above maximum capacity; committed to loving and providing the best for their special child, they shouldnât be put in the position to also have to navigate through such a polarized field of treatment.
The field of autism treatment is now ready for and would benefit greatly from a next generation of treatment protocol: Multi-Treatment Interventions. There is still much to be learned about how to sew together complementary and also sometimes seemingly diametrically opposed approaches to education and treatment.
Treatments such as Applied Behavioural Analysis (ABA, or Intensive Behaviour Intervention (IBI) in Canada), play therapies such as Floortime and The Son-Rise Program, and biomedical protocols such as DAN! each specialize in a narrow yet important range of strategies following particular ideologies of autism and treatment. More importantly, most of the highly specialized programs available to families of children with autism either do not support families to interface with other possible complimentary treatments or flat out reject and criticize treatments that are different from their own. Some proponents of ABA, for example, have been fairly vocal in rejecting play therapies, biomedical treatments, and any other ânot scientifically provenâ approach. In the same way, ardent play-therapists denounce behavioural methodologies as somehow less humane. Ironically, Dr. O. Ivar Lovaas himself, considered the pioneer of ABA, wrote in his seminal instruction manual The ME Book that ââŚno one approach will solve all the problems of developmentally disabled persons. Rather, the persons who try to help these individuals need to draw upon a variety of concepts and teaching techniques.â Furthermore, âThe âteacher-therapist-parentâ has to be flexible, innovative, and able to draw upon a variety of techniques and proceduresâ (p.3, 1981). With a nod to Dr. Lovassâ prescient remarks, I believe that the extreme âweâre right, youâre wrongâ positions simply arenât inclusive enough and that a diplomatic meeting-in-the-middle would lead to a multi-faceted approach even more appropriate and more effective than any single approach alone.
There is top-tier research underlining the fact that children with autism require a range of supports. A group of Americaâs leading psychologists and specialists surveyed and studied the field of autism treatment for over a year and concluded âNo single intervention has been shown to deal effectively with problem behaviors for all children with autism.â (Educating Children with Autism, National Research Council Report, 2001). For many readers this idea is not new nor controversial. Yet, in my practice, I continue to hear on a weekly basis of parents who have been directed by their doctor or local autism information centre to only consider ABA / IBI and to dismiss any other treatments as false hope and junk science. I meet therapist and school officials often who sincerely believe that IBI is the only scientifically âprovenâ treatment, that special diets are all baseless fads, and that parents who find that massage calms their child down are most likely being taken advantage of by a quack therapist. Just last year I participated in a funding meeting with an Ontario IBI service provider who holds the authority to determine the direction of hundreds of childrenâs programs who leaned over in my direction, nudged me in confidence and claimed that âSensory Integration Therapy was known and proven to be not helpful at best and potential harmful at worst.â He explained that he would definitely not approve any home-based programming that included Sensory Integration Therapy.
"The Symptoms manifest across a spectrum. Each child is uniquely complex."
It is important to note that in the past 5 years or so, many service providers and professionals do indeed promote what is most often called a multi-disciplinary approach to treatment. Teams of professionals from various disciplines usually include an ABA therapist, a Physical and/or Occupational therapist, a Speech and Language therapist, and a school psychologist among others. An individualized education/service plan is designed and implemented. While this is a huge step in the right direction, the various different therapies are typically provided separately from one another, often in different and separate locations by different therapists who are often not in daily communication. The design of the education plan is multi-disciplinary but the actual educational experience of the student is anything but cohesive.
After working in the field of autism for many years, as a therapist I was frustrated with having to choose to work in either one or another specific methodology. When I had returned to Canada from 12 years of work and studies in the U.S.A. for example, I was offered to work with a provincial IBI service provider but it was made clear to me that I would not be allowed to practice anything but strict IBI methods with the children. Years before, during a year of work abroad consulting for a U.S.-based treatment centre to about 75 families in the United Kingdom, I was reprimanded for âspending too much of the allotted time talking about biomedical treatments in deference to the centreâs proprietary treatmentâ. In one particular case, it was painfully evident that the young boy of 4 years I was hired to help needed medical attention. His bloated stomach, chronic constipation, and hyper-tense repetitive rocking were, in my opinion, in the way of the child benefiting from the play-therapy we were providing. Yet the restrictions of the play-therapy centre limited my ability to best help this child and family.
With this as background, I began to piece together a multi-treatment program called Intensive Multi-Treatment Intervention (IMTI). A program that would from its inception remain committed to be flexible and to evolve as new research and innovation inspires change. Recognizing that the population of amazing children with autism I work with are children who, like all children, are multi-dimensional and spectacularly complex, the program had to be highly customizable. For some children I design a program that is heavily focused on play-therapy and socialization while for others the emphasis and majority of time is spent on a more structured curriculum-based IBI approach. Note: It is not as important that the methods themselves are pure and exacting as the order and mix of the âbest practicesâ for any individual childâs unique talents, interests, and challenges. The strength of the âIMTI effectâ, as I call it, is derived from the interaction between the variety and often diverse elements of an individualized program. Order and timing of the mix is critical.
Each multi-treatment program is unique, yet there are some principles that underlie the foundation of any successful multi-treatment program. The following is a description of some of these principles illustrated with anecdotes. It is my hope that many parents and professionals will benefit from adopting these strategies which ultimately could begin to form the bridges and links between treatments which, I believe, could create more positive effects together than they ever can manage apart.
1) Learning is a biological process therefore physical health must be the priority before behavioural training and education
Joshua had already been attending playschool. He was diagnosed with PDD and was verbal, but he often struggled to pay attention. He was hyperactive and sometimes mixed up his words and thoughts. He didnât interact typically with his peers and his parents agreed he was not ready for school. After reviewing his physical health history including nutritional and diet details, I recommended that the amount of processed sugar be reduced and limited in his diet. Along with replacing sugared snacks with fruits, vegetables and natural foods (not without protests from Joshua and animated coaxing from us), Joshuaâs mother dramatically reduced his refined sugar intake while maintaining his calorie intake with more nutritious foods.
Four weeks later, during their monthly in-home training day we all agreed that Joshuaâs overall demeanor had changed positively. Throughout 40 minutes of therapy session, Joshua sat focused and still at the table as he cooperatively took turns in the Jenga building block game. He then followed his fatherâs directions to try some sit ups and push ups for fun, and sat sweetly at his motherâs side as they read a story together. Joshua was without question calmer and had a greater attention span. His language was less chaotic and he was more cooperative. Joshua still had all of his learning challenges to work through. The diet changes were not a magic cure and did not resolve most of the issues he faced with his PDD. But by first addressing Joshuaâs physical health he was able to attend more readily to the many hours of learning opportunities we would present to him. Using data collected from a medical lab, their family doctor will now take the next step to design and implement a specific protocol to ensure Joshua will continue to improve his physical health and consequently his studentship in the IMTI Program. We start with considering the physiological health of the child and possible underlying links to autism. Under the supervision and direction of a medical doctor, biological treatment can kick-start a childâs development and adds momentum to the multi-treatment effect.
"Recognising that the population of amazing autistic children with whom I work are, like all children, multidimensional and spectacularly complex, the program had to be highly customisable."
2) Learning happens more easily in cooperation with a teacher that a child trusts, feels respected by and enjoys
As obvious as this principle is, surprisingly few models of therapy incorporate or prioritize establishing and maintaining a positive and dynamic therapist-student relationship. With socialization as a âcore deficitâ challenge for people with autism, it is especially crucial that care-givers and therapists engage people with autism in extremely thoughtful and respectful ways that work for the person with autism (regardless of whether or not the mandate of the therapy is achieved). Far too often I have witnessed a treatment or therapy protocol applied to and imposed upon a child against the childâs will, in the face of protest, through struggle and conditional manipulation. The therapist prioritizes completing the treatment protocol over maintaining the quality of the relationship, believing that the target learning objective is somehow more important for the child to learn than the actual learning experience itself. But the experience of struggle and lack of trust pushes the child further from willing participation and further from wanting to learn.
I was once asked to review and provide feedback on a videoed sensory integration therapy session. A state-of-the-art day-school for students with autism delivered a video in which one particular student was filmed as he was led through a multi-station activity rotation in the school gymnasium. About 10 minutes into the video I saw the child led to an oral-motor station that frankly was painful to watch. The therapist asked the child to lay down on a gym mat which he did. But within seconds of seeing the therapist pull out the electric toothbrush, the child jumped up and ran across the large gymnasium. The video follows the scene in which two other therapists join in to corral the young student and return him to the mat. However, this time, he was held down and literally rolled up in the gym mat with his arms at his sides so that he was swaddled and not able to avoid the imminent oral-desensitization treatment. The main therapist then straddled the student- wrap, held the childâs head in place and proceeded to push the electric toothbrush in and around the childâs mouth. While the oral-motor objective was in deed completed, the damage to the student-therapist relationship far outweighed any sensory integration gains. The school staff had not established trust, rapport or cooperation with this young student. They were stuck in a vicious cycle having to use restraint strategies that just led to more resistance and the consequent need for more restraint.
Today there are many excellent strategies and programs that can be effectively used to build rapport and cooperation with students. Play-therapies, models of socialization and communication strategies when put in place first help to establish more willing studentship so that more structured curriculum-based models such as ABA can be more useful to the child who is no longer struggling against learning but is enjoying trying. This example begins to dissolve the debate between choosing either play-therapy or ABA toward using them in a complementary way. Invest a good amount of time to build the student-therapist relationship first and then use structured learning second.
3) Multi-treatment should not mean "all at once".
Understandably, with the pressure of early intervention, educators and parents are usually racing to provide as many treatment services as early after the diagnosis as possible. While undoubtedly time is of the essence, timing is equally important. I have spent the past 5 years studying, experimenting with and specializing in the order and timing of programming within the multi-treatment model. Some treatments are more effective if followed by or preceded by other treatments. For example, my students typically make greater gains and benefit more readily from peer-group play after a successful phase of intensive one-to-one adult-directed structured programming (of between 3 months up to or over one year). If this order is reversed or done concurrently, the children donât seem able to maximally benefit from the peer-play. I am currently writing a paper discussing the developmental basis for this.
The effects and benefits of each individual treatment are maximized by carefully considering the order and timing of the various treatments. In contrast, when a multi- disciplinary team implements a variety of treatment protocols all at the same time, the child may be subjected to too many different behvioural expectations and different therapist styles at once. In one program to develop compliance the child is expected to ask permission to use the bathroom while in the next class they are encouraged to simply go on their own will to develop independence. The stresses on the child of âall at onceâ programming can be compounded when a child is enrolled in diametrically opposed treatments such as half-day ABA/IBI and half-day socialization play-therapy. While a child will indeed make gains in each type of program, the benefits that each type could provide simply wonât be maximized.
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