INTERVENTIONS AND THERAPIES

"Our goal should be to help persons with autism understand and use their strengths to work around any presenting challenges so they, just like everyone else, has an equal chance at living a fulfilling and productive life". –Stephen M. Shore, EdD (US Autism Association Advisory Board Member)

Many therapies are identified below. Years ago, there were very few options. Your health care provider or services coordinator can discuss with you the best options for your child. US Autism Association does not recommend any one particular intervention or therapy. Most therapies are applicable through adulthood and not limited to young children. While early intervention is highly recommended, many adults (both young and older) have improved from many of the interventions listed in this section, especially Medical and Biomedical).

By recognizing the highly individual and diverse nature of treatment and services, US Autism Association offers information and education that reflects a variety of views and practices regarding these interventions and resources to allow maximum choice and benefit for the ASD community.

These approaches and techniques are categorized predominantly by their theories and objectives. Interventions and Therapies are arranged into four areas: Comprehensive Treatment Programs (CTP), Techniques and Therapies, Developmental, Educational, and Medical/Biomedical. Many of the therapies overlap into all of the categories. For example, Hippotherapy works with a specially trained occupational, physical, or speech therapist, who uses the horse as a mobile therapeutic tool. The action of the horse, coupled with traditional therapy, influences muscle tone, mobilizes joints, activates muscle action, increases sensorimotor integration, and improves balance and midline control. The Comprehensive Treatment Programs, while not considered more effective than other interventions, generally are considered programs that require intensive therapy 20-40 hours per week. That said, many of the programs in Techniques and Therapies or Developmental therapies could also be classified as comprehensive and require the same amount hours of therapy per week as described in the CTP. There is also overlapping therapies that could apply to all of the sections identified in Comprehensive Treatment Programs, Developmental, Educational and Techniques and Therapies.

"There are many other approaches for helping those with autism. It is only with complete and unbiased information that parents, educators and others who support people on the autism spectrum can make informed decisions on the best approach or combination of methods for educating persons on the autism spectrum." –Stephen M. Shore, EdD

Comprehensive Treatment Programs CTP refers to a classification of treatment programs that may involve intensive therapy of 20-40 hours per week. Most of the programs are designed top addressed behavior modification, although they encompass a broad area of interventions that include developmental, educational, sensory related, social communication, social skills, listening, and more. In this section you will learn about Applied Behavioral Analysis (ABA) and the other applications of ABA including Verbal Behavior (VB), Discrete trial instruction, Pivitol response therapy (PRT), TEACCH, Daily Life Therapy, The Miller Method, Relationship Development Intervention (RDI), Floortime/DIR, Cognitive-Behavioral Therapy (CBT), The Son-Rise Program, The P.L.A.Y. Project, SPELL, plus more.

Educational children with ASDs, according to the National Institutes of Health, are guaranteed free, appropriate public education under federal laws. Public Law 108-77: Individuals with Disabilities Education Improvement Act?17(2004) and Public Law 105-17: The Individuals with Disabilities Education Act IDEA18?(1997) make it possible for children with disabilities to get free educational services and educational devices to help them to learn as much as they can.

Developmental Developmental therapies in this section include Relationship Development Intervention (RDI), Floortime/DIR, Cognitive-Behavioral Therapy (CBT), The Son-Rise Program, SCERTS, and more.

Techniques and Therapies Techniques and therapies discussed in this section include Music Therapy, Hippotherapy, Art Therapy, Augmentative Communication, The Picture Exchange Communication System (PECS), Occupational Therapy, Speech Therapy, Oral Motor Therapy, Physical Therapy, Sensory Integration, and more.

Medical l and Biomedical interventions are discussed in this section.

COMPREHENSIVE INTERVENTIONS

CTP refers to a classification of treatment programs that may involve intensive therapy of 20-40 hours per week. Most of the programs are designed to addressed behavior modification, although they encompass a broad area of interventions that include developmental, educational, sensory related, social communication, social skills, listening, and more. In this section you will learn about Applied Behavioral Analysis (ABA) and the other applications of ABA including Verbal Behavior (VB) (discussed by James W. Partington, PhD, BCBA, who is an advisory board member of US Autism Association), Discrete trial instruction, Pivitol response therapy (PRT), TEACCH, Daily Life Therapy, The Miller Method, Relationship Development Intervention (RDI), Floortime/DIR, Cognitive-Behavioral Therapy (CBT), The Son-Rise Program, SCERTS, The P.L.A.Y. Project, SPELL.

Does you child have behavioral challenges Many individuals with Autism Spectrum Disorders face behavioral challenges including self-injurious, head banging, hitting, kicking, and running into traffic. In this section you will learn about Applied Behavioral Analysis (ABA) and Verbal Behavior (VB) discussed by James W. Partington, PhD, BCBA, who is an advisory board member of US Autism Association; Music Therapy, plus other behavior therapy interventions.

Applied Behavior Analysis and Verbal Behavior Dr. Partington discusses ABA and VB: Applied Behavior Analysis is a method of teaching based on the premise that speech, academics and life skills can be taught using scientific principles. ABA is based on the 20th-century work of B.F. Skinner. In 1938, Skinner publishedThe Behavior of Organisms, which described the process of learning through the consequences of behavior. Later applications of his approach to education and socially significant behavior led to what we now call Applied Behavior Analysis. ABA rewards, or reinforces, appropriate behaviors and responses because children are less likely to continue those behaviors that are not rewarded. Over time, the reinforcement is reduced so that the child can learn without the constant rewards.Research shows that children with autism respond to ABA intervention. Skills are disassembled into their smallest components, so that the children learn to master simple skills, then build toward more complicated skills.Skinner's 1957 book,Verbal Behavior,focused on the functional analysis of verbal behavior, and led to significant research by Applied Behavior Analysts, including Dr. Jim Partington. This research can be found in the journal,The Analysis of Verbal Behavior,and serves as the foundation for teaching Verbal Behavior as part of an ABA program. Applied Verbal Behavior, then, is ABA with a focus on Verbal Behavior, and the application of ABA in teaching verbal behaviors.

Cognitive-Behavioral Therapy According to the National Association of Cognitive Behavioral Therapists, Cognitive-behavioral therapy does not exist as a distinct therapeutic technique.The term "cognitive-behavioral therapy (CBT)" is a very general term for a classification of therapies with similarities. There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. However, most cognitive-behavioral therapies have the following characteristics: CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think tofeel / act better even if the situation does not change. Brief report: effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism.

Daily Life Therapy Daily Life Therapy was developed by Dr. Kiyo Kitahara of Tokyo in the 1960s. Originally a regular kindergarten school teacher, she derived her method from working with a child with autism who was included in her classroom (Kitahara, 1984). Placing heavy emphasis on group dynamics, the method incorporates physical education, art, music and academics, along with the acquisition and development of communication and daily living skills (Boston Higashi School, 1999). Specifically, Dr. Kitaharas method focuses on social isolation, anxiety, hypersensitivity and hyposensitivity, and the apparent fragility of children with autism. According the Dr. Kitahara (1984), stability of emotions is gained through the pursuit of independent living and development of self-esteem. Mastery of selfcare skills allows for the development of self-confidence and a desire to attempt other adaptive skills. The second focal point, extensive physical exercise, is used to establish a rhythm of life. Many of the exercises are founded upon principles of sensory integration and vestibular stimulation that lead to coordination and cooperative group interaction. Vigorous exercise releases endorphins, which help reduce anxiety. In addition, exercise has been found to reduce incidences of selfstimulatory behavior and aggression (Allison, Basile, & MacDonald, 1991; Elliot, Dobbin, Rose, & Soper, 1994; Koegel & Koegel, 1989), along with hyperactivity and night wakefulness while increasing time on task. Children also learn how to control their bodies as they master riding a bicycle, rollerblading, the balance disk and other Higashi exercises. Physical education is carried out in different sized groups, thus serving as a bridge to social development. Stimulation of the intellect with academics, including language arts, math, social studies and science is compatible with typical school curricula to prepare each student for inclusion opportunities. In the Higashi program, medication is not recognized as a therapeutic technique for working with children on the autism spectrum. Finally, art and music provide opportunities to gain mastery and appreciation for aesthetics. — Stephen M. Shore, EdD (from the US Autism Association Conference Proceedings Manual 2010)

Discrete Trial Therapy Discrete Trial is a process used to develop many skills, including cognitive, communication, play, social and self help skills. TeachTown, used in many educational settings (public schools), explains the discrete trial training into their program: The program breaks down individual skills into small discrete tasks and guides a student's learning through prompting and reinforcement. Each trial follows the traditional discrete trial model that has been used in multiple studies (e.g., Lovaas, 1987; Smith, Groen, & Wynn, 2000) where the discriminative stimulus is presented (i.e. the instruction or cue that the child should respond to) by presenting 1 or more images (e.g., a happy, a sad, and an angry face) with a vocal instruction (e.g., "Find the person that is happy"). Next, the child is expected to respond by selecting one of the images (e.g., clicking on the happy face) (the child can also touch the screen on touch screen monitors). If the response is correct, a positive statement is heard (e.g., "You did it!"), there is a brief (3 second) inter-trial interval (i.e. pause between trials) and the next trial is presented. If the response is not correct, the correct answer is shown.

Floortime/DIR Floortime (or DIRFloortime) is a specific technique to both follow the child's natural emotional interests (lead) and at the same time challenge the child towards greater and greater mastery of the social, emotional, and intellectual capacities. With young children these playful interactions may occur on the floor, but go on to include conversations and interactions in other places. DIRFloortime emphasizes the critical role of parents and other family members because of the importance of their emotional relationships with the child. The DIR Model, however, is a comprehensive framework which enables clinicians, parents and educators to construct a program tailored to the child's unique challenges and strengths. Central to the DIR Model is the role of the child's natural emotions and interests which has been shown to be essential for learning interactions that enable the different parts of the mind and brain to work together and build successively higher levels of social, emotional, and intellectual capacities. It often includes, in addition to Floortime, various problem-solving exercises and typically involves a team approach with speech therapy, occupational therapy, educational programs, mental health (developmental-psychological) intervention and, where appropriate, augmentative and biomedical intervention.

The Miller Method The Miller method, which embodies developmental, cognitive and systems components, builds on the work of Heinz Werner, Jean Piaget, Lev Vygotsky and Ludwig von Bertalanffy (Miller & Eller-Miller, 1989). The developmental aspect of the approach looks at children with autism spectrum disorder as being completely or partially stuck at earlier stages of development and therefore structures its interventions to spur on development. The cognitive aspect strives to promote cognitive development by structuring the environment so as to be conducive to increased cognitive development. This emphasis on thought processes contrasts with other, more behaviorally oriented approaches, which devote most of their focus to stimuli and response as the explanations of the way child with autism functions in the world. Finally, the systems address the roles systems play in restoring normal development in two ways. The first is to build on the repetitive behaviors (systems) the children have managed to achieve. A system is defined as a coherent organization (functional or non-functional) of behavior involving an object or event (A. Miller, personal communication, July, 1999). Systems range from quite small (mini-systems) such as flicking light switches on and off to quite elaborate such as taking groceries from a bag and putting them where they belong in cupboard or refrigerator (A. Miller, personal communication, July, 1999). The hallmark of a successfully formed system is a desire in the child to continue the activity after it has been interrupted. The second way is to teach children certain behaviors by introducing repetitive activities. These activities or systems are designed to teach behaviors to a child who has not been able to otherwise develop them spontaneously by him or herself. (Miller & Eller-Miller, 1985) — Stephen M. Shore, EdD (from the US Autism Association Conference Proceedings Manual 2010)

Pivotal response therapy (PRT) Pivotal Response Treatment (PRT), also referred to asPivotal Response Therapy,Pivotal Response Training,Pivotal Response Teaching or Pivotal Response Intervention is a behavioral intervention model based on the principles of ABA. PRTwas previously called the Natural Language Paradigm (NLP), which has been in development since the 1970s.

The P.L.A.Y. Project Created by Richard Solomon, MD in 2001, and based on the DIR (Developmental, Individualized, Relationship-based) theory of Stanley Greenspan, MD, The P.L.A.Y. Project program emphasizes the importance of helping parents become their child's best P.L.A.Y. partner. The P.L.A.Y. Project has four key components: Diagnosis, Home, Consulting, and Training Research. The P.L.A.Y. Project follows The National Academy of Sciences recommendations for the education of young children with autistic spectrum disorders. Parents and professionals should: Begin interventions early (18 months to 5 years;) Use intensive intervention 25 hours per wee;k Have a teacher/play partner to child ratio of 1:1 or 1:2; Use interventions that are engaging; Have a strategic direction (e.g. social skills, language, etc.).

Relationship Development Intervention (RDI) Developed by Dr. Steven Gutstein and Dr. Rachelle Sheely, relationship development intervention is a parent-based model program that provides a means for individuals with autism and Asperger disorder to learn about and experience authentic emotional relationships in a gradual, systematic way. The enjoyable activities in this program emphasize foundation skills such as social referencing, regulating behavior, conversational reciprocity and synchronized actions.

SCERTS SCERTSis an innovative educational model for working with children with autism spectrum disorder (ASD) and their families. It provides specific guidelines for helping a child become a competent and confident social communicator, while preventing problem behaviors that interfere with learning and the development of relationships. It also is designed to help families, educators and therapists work cooperatively as a team, in a carefully coordinated manner, to maximize progress in supporting a child. The acronym SCERTS refers to the focus on: SC - Social Communication the development of spontaneous, functional communication, emotional expression, and secure and trusting relationships with children and adults; ER - Emotional Regulation - the development of the ability to maintain a well-regulated emotional state to cope with everyday stress, and to be most available for learning and interacting; TS Transactional Support the development and implementation of supports to help partners respond to the child's needs and interests, modify and adapt the environment, and provide tools to enhance learning (e.g., picture communication, written schedules, and sensory supports). Specific plans are also developed to provide educational and emotional support to families, and to foster teamwork among professionals.

The Son-Rise Program The Son-Rise Program Start-Up is a 5-day group training program for parents, relatives and professionals looking to facilitate meaningful progress in their children (ages 18 months through 60 years) challenged by Autism, Autism Spectrum Disorders, Pervasive Developmental Disorder (PDD), Asperger's Syndrome, High Functioning Autism and other related developmental difficulties. Exciting, inspiring and diverse presentations by a group of seasoned and dedicated teachers, will deliver to you the autism strategies, expertise, motivation and knowledge honed through years of working with thousands of families and children with Autism Spectrum Disorders. At the end of this course, you will have all the tools necessary to design and implement your own home-based Son-Rise Program, as well as the skills and attitude to impact your child's growth in all areas of learning, communication, development and skill acquisition.

SPELL The SPELL framework recognizes the individual and unique needs of each child and adult and emphasizes that all planning and intervention be organized on this basis. They believe that a number of interlinking themes are known to be of benefit to children and adults with an autistic spectrum disorder and that by building on strengths and reducing the disabling effects of the condition, progress can be made in personal growth and development with the promotion of opportunity and as full a life as possible. The acronym for this framework isSPELL. SPELL stands forStructure, Positive(approaches and expectations),Empathy,Low arousal,Links. SPELL draws on and is complementary to other approaches, notably TEACCH. (National Autistic Society).

TEACCH TEACCH is an evidence-based service, training, and research program for individuals of all ages and skill levels with autism spectrum disorders. Established in the early 1970s by Eric Schoplerand colleagues, theTEACCH program has worked with thousands of individuals with autism spectrum disorders and their families.TEACCH provides clinical services such as diagnostic evaluations, parent training and parent support groups, social play and recreation groups, individual counseling for higher-functioning clients, and supported employment. In addition,TEACCH conducts training nationally and internationally and provides consultation for teachers, residential care providers, and other professionals from a variety of disciplines. Research activities include psychological, educational, and biomedical studies. The administrative headquarters of theTEACCH program are in Chapel Hill, North Carolina, and there are seven regionalTEACCH Centers around the state of North Carolina. Most clinical services from the TEACCH centers are free to citizens of North Carolina.

DEVELOPMENTAL INTERVENTIONS

Developmental therapies in this section include Relationship Development Intervention (RDI), Floortime/DIR, Cognitive-Behavioral Therapy (CBT), The Son-Rise Program, SCERTS, Computer Software Programs, Apps for Tablets.

Apps for Tablets There are hundreds of apps for tablets (iPad, iPhone, iPod touch, and Android) for autism spectrum disorders. Go to apps on your tablet or phone and search autism.

Cognitive-Behavioral Therapy (CBT) According to the National Association of Cognitive Behavioral Therapists, Cognitive-behavioral therapy does?not?exist as a distinct therapeutic technique.?The term "cognitive-behavioral therapy (CBT)" is a very general term for a classification of therapies with similarities.? There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. However, most cognitive-behavioral therapies have the following characteristics: CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the idea that our thoughts?cause our feelings and behaviors, not external things, like people, situations, and events.? The benefit of this fact is that we can change the way we think to?feel / act better even if the situation does not change.? Brief report: effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism.

Computer Software programs There are many programs specifically designed for autism spectrum disorders. They are used for additional educational intervention.

Floortime/DIR Floortime (or DIRFloortime) is a specific technique to both follow the child's natural emotional interests (lead) and at the same time challenge the child towards greater and greater mastery of the social, emotional, and intellectual capacities. With young children these playful interactions may occur on the floor, but go on to include conversations and interactions in other places. DIRFloortime emphasizes the critical role of parents and other family members because of the importance of their emotional relationships with the child. The DIR Model, however, is a comprehensive framework which enables clinicians, parents and educators to construct a program tailored to the child?s unique challenges and strengths. Central to the DIR? Model is the role of the child?s natural emotions and interests which has been shown to be essential for learning interactions that enable the different parts of the mind and brain to work together and build successively higher levels of social, emotional, and intellectual capacities. It often includes, in addition to Floortime?, various problem-solving exercises and typically involves a team approach with speech therapy, occupational therapy, educational programs, mental health (developmental-psychological) intervention and, where appropriate, augmentative and biomedical intervention.

Relationship Development Intervention (RDI) Developed by Dr. Steven Gutstein and Dr. Rachelle Sheely, relationship development intervention is a parent-based model program that provides a means for individuals with autism and asperger disorder to learn about and experience authentic emotional relationships in a gradual, systematic way. The enjoyable activities in this program emphasize foundation skills such as social referencing, regulating behavior, conversational reciprocity and synchronized actions.

SCERTS SCERTS is an innovative educational model for working with children with autism spectrum disorder (ASD) and their families. It provides specific guidelines for helping a child become a competent and confident social communicator, while preventing problem behaviors that interfere with learning and the development of relationships. It also is designed to help families, educators and therapists work cooperatively as a team, in a carefully coordinated manner, to maximize progress in supporting a child. The acronym SCERTS refers to the focus on Social Communication that is the development of spontaneous, functional communication, emotional expression, and secure and trusting relationships with children and adults. Emotional Regulation - the development of the ability to maintain a well-regulated emotional state to cope with everyday stress, and to be most available for learning and interacting; (TS) Transactional Support - the development and implementation of supports to help partners respond to the child's needs and interests, modify and adapt the environment, and provide tools to enhance learning (e.g., picture communication, written schedules, and sensory supports). Specific plans are also developed to provide educational and emotional support to families, and to foster teamwork among professionals.

The Son-Rise Program The Son-Rise Program Start-Up is a 5-day group training program for parents, relatives and professionals looking to facilitate meaningful progress in their children (ages 18 months through 60 years) challenged by Autism, Autism Spectrum Disorders, Pervasive Developmental Disorder (PDD), Asperger's Syndrome, High Functioning Autism and other related developmental difficulties. Exciting, inspiring and diverse presentations by a group of seasoned and dedicated teachers, will deliver to you the autism strategies, expertise, motivation and knowledge honed through years of working with thousands of families and children with Autism Spectrum Disorders. At the end of this course, you will have all the tools necessary to design and implement your own home-based Son-Rise Program, as well as the skills and attitude to impact your child?s growth in all areas of learning, communication, development and skill acquisition.

EDUCATIONAL INTERVENTIONS

According to the National Institutes of Health, children with ASDs are guaranteed free, appropriate public education under federal laws. Public Law 108-77: Individuals with Disabilities Education Improvement Act17 (2004) and Public Law 105-17: The Individuals with Disabilities Education Act IDEA18 (1997) make it possible for children with disabilities to get free educational services and educational devices to help them to learn as much as they can. Each child is entitled to these services from age three through high school, or until age 21[age 22 in some states], whichever comes first.

The laws state that children must be taught in the least restrictive environment, appropriate for that individual child. This statement does not mean that each child must be placed in a regular classroom. Instead, the laws mean that the teaching environment should be designed to meet a child's learning needs, while minimizing restrictions on the child's access to typical learning experiences and interactions. Educating persons with ASDs often includes a combination of one-to-one, small group, and regular classroom instruction.

To qualify for access to special education services, the child must meet specific criteria as outlined by federal and state guidelines. You can contact a local school principal or special education coordinator to learn how to have your child assessed to see if he or she qualifies for services under these laws.

If your child qualifies for special services, a team of people, including you and your family, caregivers, teachers, school psychologists, and other child development specialists, will work together to design an Individualized Educational Plan (IEP) 19 for your child. An IEP includes specific academic, communication, motor, learning, functional, and socialization goals for a child based on his or her educational needs. The team also decides how best to carry out the IEP, such as determining any devices or special assistance the child needs, and identifying the developmental specialists who will work with the child.

The special services team should evaluate and re-evaluate your child on a regular basis to see how your child is doing and whether any changes are needed in his or her plan.

Services provided at schools generally consist of Speech Therapy, Occupational Therapy, Physical Therapy, and may incorporate programs such as SCERTS, PECS, TeachTown, augmentative communication devices and programs, and others depending on the public school district.

MEDICAL INTERVENTIONS

There are many medical and biomedical approaches in treating autism spectrum disorders. We will identify different methods used to treat individuals with ASD. THE CONTENT IS NOT INTENDED IN ANY WAY TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH PROVIDER WITH ANY QUESTIONS YOU MAY HAVE REGARDING A MEDICAL CONDITION.

US Autism Association does not recommend any one particular intervention or therapy. Most therapies are applicable through adulthood and not limited to young children. While early intervention is highly recommended, many adults (both young and older) have improved from many of the interventions listed in this section.

By recognizing the highly individual and diverse nature of treatment and services, US Autism Association offers information and education that reflects a variety of views and practices regarding these interventions and resources to allow maximum choice and benefit for the ASD community.

One of the most important decisions in treatment is choosing a physician. Selecting a physician can be very difficult. This topic is discussed in the Parent/Practitioner Program: Monitoring and charting your child's development or your own if your are an adult with ASD; How to choose a physician; Respecting your doctor and earning your doctor's respect; Ten steps to effective listening; Interviewing and negotiating with your health care practitioner.

Research has shown that many children and adults, with autism spectrum disorders, endure multiple medical problems. Coexisting medical problems such as anxiety and seizure disorders should be addressed with your health care provider. Physicians will refer to this topic as Comorbidity (the presence of one or more disorders or diseases in addition to ASD).

The Biomedical Concept Biomedical approaches are based on scientific research that identify underlying causes which include metal toxicity, nutritional deficiencies, gastrointestinal problems and other issues. In other words, the physician treats the whole body. Dr. Phillip C. DeMio, MD, provides "An in Depth Look Into Dietary Interventions and Digestive and Gastrointestinal Problems" from a recent US Autism Association conference presentation.

Dr. DeMio explains the Biomedical concept: "As espoused by Dr. Bernard Rimland more than 40 years ago, persons with Autism Spectrum Disorders (ASD) have a bona fide medical disease, not a psychiatric disorder. ASDs do not result from bad parenting, nor do they just happen. Underlying medical abnormalities in metabolism, gastrointestinal/nutritional function, the detoxification system, and immunology all as a group lead to a severe lack of normal brain support with resultant abnormal behaviors that we know as ASDs. Just as the person with a head injury from a car accident acts abnormally and has deficits in language, so it is that ASDs, too, have a biological medical basis as to why they occur."

"The vast majority of persons on the Autism Spectrum (ASD) who make significant gains from biomedical treatments will require care that addresses the triad of dietary intervention, digestive/gastrointestinal problems, and detoxification techniques. Practical implementation of treatment programs will be given, including such diets as gluten-free/casein-free, specific carbohydrate, low oxalate, pigment restriction (e.g., phenols and salicylates), and others. Particular situations in which one diet would be chosen over another will be highlighted. Pitfalls must be avoided in order to foster greater ease of implementation, success (symptom control), and reduction in the complications that can occur with each diet. Digestive and gastrointestinal (GI) topics will touch upon overgrowth of yeast and other dysbioses (abnormal GI germs), leaky gut, abdominal pain, chewing problems, swallowing difficulties, acid reflux, diarrhea, constipation, malabsorption of nutritional substances, and how these all connect to symptoms in our children and adults with spectrum disorders."

Dietary Intervention: "The gluten-free casein-free diet is a mainstay for many ASD patients, and is often the first diet attempted on the journey to help your family member or patient. The major theory is that of false endorphins (based on poor digestion and intestinal barrier dysfunction [so-called leaky gut]), with the potential of sweeping benefits from immunologic to cognitive, and back full circle to the GI tract. This is the theory that best explains the clinical and lab response, though allergy and excitotoxicity probably play a role. Thus gluten foods, namely anything derived from wheat, barley, oats, or rye, (i.e., many staples) is excluded from the diet, as is anything from a dairy source (milk, butter, yogurt, ice cream, etc.). A withdrawl can occur, so the diet is usually implemented no faster than over a 3 week period. Benefits are expected in a few weeks but may continue to manifest over some months. Yeast control must simultaneously be done to improve success of the program.

Carbohydrate-restrictive diets can be from a gamut that excludes all carbs (starch and sugar) in an effort to circumvent difficulties in digestion that lead to residual food particles that feed yeast, some bacteria, and other disease-producing germs. The specific carbohydrate diet, invented and practiced beginning about sixty years ago by Dr. S. V. Haas, and more recently espoused by the late Elaine Gottschall, restricts carbs that are hardest to digest, so that most tree fruits, nuts (sometimes blanched), and most legumes and nonstarchy garden vegetables are allowed. Probiotics are controversial here, as is dairy, so that subgroups of the diet are accepted by some practitioners and support groups, while others shun them and have their own variants revolving around these differentials. Complications can include bacterial (?putrefactive?) shift, often some months into the diet.

Oxalates are largely found in plant foods. These are substances that can sequester minerals, both toxic, e.g. mercury, and essential, e.g. zinc, i.e., the body can neither properly detoxify heavy metals nor utilize nutritive minerals because the oxalates ?freeze? them in the body. High oxalate foods are often those that we give our kids when implementing some of the other diets discussed here, so that the oxalate issue may emerge in the midst of a treatment program. Unlike some diets, this is not so often an all-or-none? diet, as steady improvement frequently occurs with further and further reduction in dietary oxalates. Also, the GI tract can be used as a blocker and demolition area to further help with the problem of oxalates, eg with divalent cation trickles and certain probiotics.

Pigments in foods can cause symptoms in our patients. A major group is that of phenols and salicylates, which includes a varied group of highly colored and sometimes colorless but spicy flavors in foods. These are in both synthetic groups (which are often the worst at producing symptoms) and in natural forms, eg red, purple, and some green fruits. These can all tax the sulfation system, which is often lacking in our ASD patients. Some of these substances also foster imbalances of toxic and essential metals in the body. Natural foods that are chopped and cooked can reduce the load, as can some enzymes. Other pigment-related diets include Sarah?s diet, which avoids carotenes, eg orange, yellow, red, purple, and sometimes green pigments, mostly in vegetables. Again, as we move away from one food on a special diet, we may increase carotenes. They are also in many supplements that are commonly given to our kids, so these may need modification.

Enzymes: these can, in a small number of patients, substitute for some of the above diets. More often, though, when enzymes help, they do so in conjunction with a completely implemented diet. Enzymes, too, can have undesired (?side?) effects, eg regression by release of toxic peptides, diarrhea, and constipation. Therefore enzymes, like any other treatment can play an important role in a whole program and may help many persons while not being as helpful to others.

Digestion and gastrointestinal issues: From chewing difficulties to swallowing abnormalities to reflux to constipation to diarrhea (often after vaccines in the first day of life), the GI tract is often where parents first notice problems in children even ?before? their ASD cognitive issues are apparent. Yeast is a pathologic (symptom-causing) microbe in the GI tracts of our kids, and is present in the overwhelming majority of cases. Many patients have bacteria that can add to the symptoms, or will later emerge. Due to the above or other problems, many ASD patients suffer from frequent abdomen pain, which can for them (as with anyone) make their lives miserable, and, more specifically, lead to interruption in the benefits of school, play, and therapies. Leaky gut can allow entrance of toxic byproducts and metals excessively into the body, leading to cognitive changes. Inability to completely uptake nutrition from the diet can ensue when the GI tract is a battleground, leading to deficiencies in the face of an otherwise healthy diet.

Other biomedical interventions include Hyperbaric Oxygen Therapy, Methyl B12, anti-viral and anti-fungal treatment, Magnesium and B6, and others that are discussed in Dr. DeMio's presentations on our YouTube channel.

To understand the dynamic category of nutritional supplements, the Physicians Desk Reference (PDR) for Nutritional Supplements creates an invaluable reference for consumers and health care professionals. You will discover which benefits are clinically verified and which remain speculative. The PDR includes potential side effects and interactions to the very real dangers of toxicity and overdose of these products.

TECHNIQUES AND THERAPIES

Techniques and therapies discussed in this section include Music Therapy, Hippotherapy, Art Therapy, Augmentative Communication, The Picture Exchange Communication System (PECS), Occupational Therapy, Speech Therapy, Oral Motor Therapy, Physical Therapy, and Sensory Integration.

Art Therapy Art therapy is recognizing feelings and helping to identify them in oneself and others. The goals of art therapy are to move toward healing and growth. It is process oriented, it is self-expressive. It is therapeutic in that it is multi-sensory, involves visual-perceptual skills, requires coordination and fine motor control, teaches people to use objects purposefully, to follow directions, and build communication skills.

Augmentative Communication Augmentative Communication uses visual modes such as pictures, symbols and signs and promotes communication and language in children with severe communication deficits and poor verbal imitation skills. "Communication is based on the use of the individual words of our language. True communication is spontaneous and novel. When we cannot speak naturally, other methods of selecting words can be used. These methods have two parts: the language representation method and the physical selection technique. In some cases, such as with sign language, the communication may be direct to the partner. An electronic augmentative and alternative communication (AAC) system may include speech output which then transmits the words to the communication partner" (American Speech - Language Hearing Association).

Hippotherapy Hippotherapy is a physical, occupational, and speech-language therapy treatment strategy that utilizes equine movement as part of an integrated intervention program to achieve functional outcomes.Equine movement provides multidimensional movement, which is variable, rhythmic and repetitive. The horse provides a dynamic base of support, making it an excellent tool for increasing trunk strength and control, balance, building overall postural strength and endurance, addressing weight bearing, and. motor planning. Equine movement offers well-modulated sensory input to vestibular, proprioceptive, tactile and visual channels. During gait transitions, the patient must perform subtle adjustments in the trunk to maintain a stable position. When a patient is sitting forward astride the horse, the horse?s walking gait imparts movement responses remarkably similar to normal human gait. The effects of equine movement on postural control, sensory systems, and motor planning can be used to facilitate coordination and timing, grading of responses, respiratory control, sensory integration skills and attentional skills. Equine movement can be used to facilitate the neurophysiologic systems that support all of our functional daily living skills. (American Hippotherapy Association).

Music Therapy Music therapy is a well-established allied health profession similar to occupational and physical therapy. It consists of using music therapeutically to address behavioral, social, psychological, communicative, physical, sensory-motor, and/or cognitive functioning. Music provides concrete, multi-sensory stimulation (auditory, visual, and tactile). The rhythmic component of music is very organizing for the sensory systems of individuals diagnosed with autism. As a result, auditory processing and other sensory-motor, perceptual/motor, gross and fine motor skills can be enhanced through music therapy. (American Music Therapy Association).

Occupational Therapy In its simplest terms, occupational therapists and occupational therapy assistants help people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations). Common occupational therapy interventions include helping children with disabilities to participate fully in school and social situations, helping people recovering from injury to regain skills, and providing supports for older adults experiencing physical and cognitive changes. Occupational therapy services typically include an individualized evaluation, during which the client/family and occupational therapist determine the person?s goals, customized intervention to improve the person?s ability to perform daily activities and reach the goals, and an outcomes evaluation to ensure that the goals are being met and/or make changes to the intervention plan. Occupational therapy services may include comprehensive evaluations of the client?s home and other environments (e.g., workplace, school), recommendations for adaptive equipment and training in its use, and guidance and education for family members and caregivers. Occupational therapy practitioners have a holistic perspective, in which the focus is on adapting the environment to fit the person, and the person is an integral part of the therapy team. (American Occupational Therapy Association).

Oral Motor Therapy "Oral motor" has been defined in a variety of ways. Many of the strategies of the 1950's and '60's were primarily stimulation techniques, such as brushing (pressure massage), icing (thermal stimulation), quick stretch (tapping), and vibration (manual and mechanical). These strategies have been used by physical and occupational therapists to prepare a muscle area for movement. These strategies cannot change the range of movement of a muscle or the strength of a muscle without additional muscle movement. Other oral motor techniques require the individual's cognitive cooperation to follow a command in order to complete a movement. But what if the individual cannot cooperate cognitively, or, due to significant motoric involvement, cannot follow the therapist's verbal directive to "lick your lips," or "move your tongue up toward your nose," or "round and spread your lips?" Many individuals with impaired oral motor skills are not able to follow a command for oral movement. To better serve such individuals, Debra Beckman has, since 1975, worked to develop these specific interventions which provide assisted movement to activate muscle contraction and to provide movement against resistance to build strength. The focus of these interventions is to increase functional response to pressure and movement, range, strength, variety and control of movement for the lips, cheeks, jaw and tongue. The interventions needed are determined by an assessment, the Beckman Oral Motor Protocol, which uses assisted movement and stretch reflexes to quantify response to pressure and movement, range, strength, variety and control of movement for the lips cheeks, jaw, tongue and soft palate. The assessment is based on clinically defined functional parameters of minimal competence and does not require the cognitive participation of the individual. Because these components of movement are functional, not age specific, the protocol is useful with a wide range of ages (birth to geriatric) and diagnostic categories. (Beckman).

The Picture Exchange Communication System (PECS) PECS was developed in 1985 as a unique augmentative/alternative communication intervention package for individuals with autism spectrum disorder and related developmental disabilities. First used at the Delaware Autistic Program, PECS has received worldwide recognition for focusing on the initiation component of communication. PECS does not require complex or expensive materials. It was created with families, educators, and resident care providers in mind, so is readily used in a range of settings. PECS begins by teaching an individual to give a picture of a desired item to a "communicative partner", who immediately honors the exchange as a request. The system goes on to teach discrimination of pictures and how to put them together in sentences. In the more advanced phases, individuals are taught to answer questions and to comment. The PECS teaching protocol is based on B.F. Skinner's book,?Verbal Behavior, such that functional verbal operants are systematically taught using prompting and reinforcement strategies that will lead to independent communication. Verbal prompts are not used, thus building immediate initiation and avoiding prompt dependency. PECS has been successful with individuals of all ages demonstrating a variety of communicative, cognitive and physical difficulties. Some learners using PECS also develop speech. Others may transition to a voice output system. The body of research supporting the effectiveness of PECS continues to expand, with research from countries around the world. (Pyramid Educational Consultants).

Physical Therapy Physical therapy (PT) uses therapeutic exercise and other interventions to improve posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and to reduce pain. Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiologic principles. (Blue Cross Blue Shield Manual).

Sensory Integration Sensory integration is a specialty area of occupational therapy that is based on over 40 years of theory and research. The term ?sensory integration refers to: The way the brain organizes sensations for engagement in occupation; A theory based on neuroscience that provides perspective for appreciating the sensory dimensions of human behavior; A model for understanding the way in which sensation affects development; Assessments including standardized testing, systematic observation, and parent or teacher interviews that identify patterns of sensory integration dysfunction; Intervention strategies that enhance information processing, praxis, and engagement in daily life for individuals, populations and organizations. (University of Southern California Division of Occupational Science and Occupational Therapy).

Marlo Payne Thurman, US Autism Association Advisory Board Member, discusses "The Continuums of Autism: Cognition, Sensory Processing, and Behavior", and more specifically Sensory Modulation and Sensory Integration. "Children of higher intelligence take in more information than their peers of average cognitive ability. However, because the sensory skills of filtering, regulation and modulation mature with age, innately asynchronous sensory development in the gifted, twice-exceptional and high functioning autism populations places our most intelligent youth at risk for academic, social and emotional problems. When compounded by learning disabilities, most asynchronous children simply cannot access enough cognitive energy to compensate and function successfully in their day-to-day lives. This, in turn, leads to cognitive and emotional fatigue, heightened physiological arousal and ultimately mental health symptoms. This paper will discuss the unique relationship between intelligence and sensory regulation, and will illustrate the impact of modulation abilities on learning, social and emotional function and the mental health diagnoses commonly seen in our most intelligent, yet out-of-sync populations".

"It is not at all surprising then, that in my experience with over 5,000 out-of-sync children, most have sensory arousal issues. Furthermore, I have yet to see an autistic child without severe sensory modulation difficulties. This is not necessarily the same however, as sensory integration dysfunction, although all kids can have that too. Let me explain. Sensory integration disorders are usually thought of as inaccurate registration of sensory information. Sensory modulation disorder however, is best described as the inability to filter and process only what is important."

Speech Therapy When a person is unable to produce speech sounds correctly or fluently, or has problems with his or her voice, then he or she has a?speech disorder. Difficulties pronouncing sounds, or articulation disorders, and stuttering are examples of speech disorders. When a person has trouble understanding others (receptive language), or sharing thoughts, ideas, and feelings completely (expressive language), then he or she has a?language disorder. Speech Disorders may include: Childhood Apraxia of Speech, Dysarthria, Orofacial Myofunctional Disorders, Speech Sound Disorders: Articulation and Phonological Processe,s Stuttering, and Voice. (American Speech - Language Hearing Association).