B.J. Freeman, Ph.D. Professor Emerita, Medical Psychology UCLA School of Medicine ~ Long Beach ASA April 28, 2009

Transcription

1 Update on Treatment for Autism Spectrum Disorders: What We Know 2009 B.J. Freeman, Ph.D. Professor Emerita, Medical Psychology UCLA School of Medicine ~ Long Beach ASA April 28, 2009

2 INTRODUCTION Kanner (1943) in his now famous paper Autistic Disturbances of Affective Contact introduced the word autism into the scientific literature.

3 He hypothesized that autism was an inborn constitutional error where children are born lacking motivation for social interaction (social isolation). He also described profound disturbances in communication and resistance to change. While Kanner s clinical description of autism had endured, many issues raised by his initial paper have now been refuted. For example -

4 Kanner observed that parents were usually successful, educated people. He hypothesized that this led to problems between parent and child, particularly the mother and child. We now know that children with autism are found across all social classes.

5 Kanner also speculated that children with autism had trouble relating to everyone in their environment. We now know that the primary deficit in autism is relating to peers.

6 Recent research has focused on genetics and other medical causes for autism. Kanner had initially speculated that children with autism could not have other medical conditions.

7 Kanner also misconstrued the role of intellectual disability in that he felt that the majority of children with autism were not mentally retarded.

8 What is Autism? Autism is now viewed as a spectrum of disorders and the term Autism Spectrum Disorders (ASDs) is frequently used.

9 Autism Spectrum Disorders are best viewed as social communication learning disabilities. For example, some children have trouble learning to read and some have trouble learning to do math. Children with ASDs have trouble learning social communication skills.

10 ASDs represent a wide spectrum of disabilities, and all children require intense multidisciplinary evaluations and intense early intervention that focus on teaching social communication skills in the natural environment.

11 Scientific evidence supports the conclusion that ASD is a behavioral syndrome that results from various brain abnormalities. These abnormalities develop as the result of genetic predispositions and early environmental - in all likelihood while in utero - insults.

12 While recent scientific advances continue to provide important insights into the development of ASDs, the etiology is complex and the scientific causes remain unknown. (National Research Council, 2001)

13 A Few Facts about ASDs: 1. Autism occurs in 1 in 150 births. 2. Early diagnosis & intervention can change the outcome for children with ASDs. 3. No matter how the child with autism is affected, intensive intervention is necessary. (Educating Children with Autism, National Research Council, 2001)

14 4. Research has shown Applied Behavior Analysis to be the most effective intervention for all children with ASDs. 5. Recent research studies have shown that even very mild social communication issues in younger children result in significant behavior problems as they get older. (Skuse et al, 2009)

15 6. The majority of ASD children are not receiving appropriate intervention.

16 Treatment The increase in the rate of children diagnosed with ASDs has generated an increased interest in services and treatments for children. (Frombonne, 2001)

17 Since the first descriptions of the disorder, a host of different treatment modalities have been prescribed that usually have been tied to some underlying belief concerning the cause of ASDs.

18 The literature contains many case studies and much anecdotal evidence pertaining to these treatments. However, few have been studied in a systematic controlled fashion.

19 The current consensus suggests that the best approach for intervention for the core symptoms of ASDs includes a program of coordinated, intensive behavioral and educational interventions.

20 The most tested of these interventions is applied behavior analysis (ABA), which has been shown to significantly improve the core symptoms in almost all children. Complete recovery of all symptoms is Complete recovery of all symptoms is rare, but the number of children showing recovery has been increasing over the past few years.

21 In spite of overwhelming scientific evidence that the etiology of ASDs remains unknown, many theories designed to treat the cause of ASDs have arisen. These treatments have often been widely publicized as miracle cures.

22 These cures receive widespread usage in spite of the absence of supportive scientific data. Even in the presence of contradictory data and warnings from scientists, these treatments continue to be passionately promoted by their supporters.

23 These treatments are known as Complementary and Alternative Medicine. (CAM)

24 Over the past few years, there has been a lack of agreement concerning the best combination of treatment approaches and expected outcomes. Combined with the fact that many children Combined with the fact that many children with ASDs have poor access to effective treatments, many families have turned to CAM strategies.

25 In addition, many children with ASDs have associated medical difficulties that standard treatments often fail to take into account. Sleep disorders and gastrointestinal problems are increasingly reported and cause stress to families. Many CAM treatments claim to address these ancillary symptoms. (Richdale 1999; Horvath, Perman 2002)

26 WHAT ARE CAMs? Complementary and Alternative Medicine has been identified as a broad domain of healing resources that encompasses all health system modalities and practice and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system...

27 and as strategies that have not met the standards of clinical effectiveness either through randomized control, clinical trials or through the consensus of the biomedical community. (AAP, 2001)

28 In reviews of the safety and effectiveness of non-traditional approaches to the treatment of ASDs, (Hyman & Levy, 2000; Levy & Hyman, 2002) treatment programs were divided into four categories:

29 1. Unproven benign biological treatments that are commonly used, but have no basis in theory. This category includes vitamin supplements such as B6 & magnesium, gastrointestinal medications and antifungal agents.

30 2. Unproven benign biological treatments that have some basis in theory. This category includes gluten-free, casein-free diets, vitamin C & secretin.

31 3. Unproven potentially harmful biological treatments. This category includes immunoglobulins, large doses of vitamin A, antibiotics, antiviral agents, alkaline salts & withholding immunizations.

32 4. Non-biological treatments This category includes treatments such as auditory integration training, interactive metronome, spinal manipulation & facilitated communication.

33 Nickel (1996) reports that 50% of children with autism use these and other unconventional treatment strategies. In many cases the primary physicians and therapists are unaware of the use of these treatments.

34 Pinto & Martin (2003) examined the prevalence of CAM strategies and family characteristics associated with their use. The sample consisted of children recently diagnosed with autism at Children s Hospital of Philadelphia.

35 The authors reviewed 284 charts and found that more than 30% were using some CAM strategy, and that 9% were using potentially harmful CAM strategies. They concluded that the high prevalence of CAM usage among a recently diagnosed sample indicates the need for every clinician to discuss CAMs with families early in the assessment process.

36 What is the Scientific Method? The majority of CAM strategies have not been subjected to rigorous scientific investigation. Before reviewing specific CAMs Before reviewing specific CAMs advocated as effective for ASDs, it is important to understand what constitutes a scientific study.

37 Treatment studies in the field of autism have been extremely difficult to interpret. Currently, funding agencies and professional journals have set minimum standards in design and description for intervention studies:

38 1. All intervention studies have to provide the following information: Adequate information concerning the sample and about the families who participated, and those who chose not to participate or withdrew from participation.

39 Chronological age, Autism Diagnostic Interview, Autism Diagnostic Observation Schedule, gender and race Family characteristics and socioeconomic status Relevant health or other biological impairments

40 2. Studies need to include a description of the intervention in such detail that an external group could replicate it. 3. Detailed documentation is critical, 3. Detailed documentation is critical, especially if no treatment manual is available for the intervention described.

41 The fidelity of treatment and the degree of implementation, as well as specific objectives measured such as expected outcome assessed at regular intervals must be independent of the intervention in terms of both the evaluators and the measures, and include broad immediate and long-term effects on the children and families, particularly generalization and maintenance of skills.

42 In the CAM field, much of the data that is reported is anecdotal pseudoscience, and is based more on social validity than on scientific methods.

43 Biological Treatments Several factors have come together to increase the popularity of biologically oriented treatments for ASDs. These include:

44 Increasing consensus that ASD is a neurological condition. Increased use of psychotropic medications in psychiatry. Increased use of homeopathic, herbal, vitamin and other alternative medical approaches.

45 Some of these treatments have been promoted as producing extraordinary benefits and miraculous cures, even in the absence of supportive data and in some instances in the face of disconfirmatory data.

46 Medical Tests Some proponents attempt to legitimize their treatment by the use of medical tests. The use of these tests - and thus the treatments - are generally based on unproven theories regarding the underlying cause(s) of ASDs.

47 Barrett (2004) reviewed the use of what he labeled dubious medical tests or those that have little or no diagnostic value. These include: Blood tests (circulating IgE & IgG, food immune complexes, EIISA/ACT) Mercury testing for amalgam toxicity Saliva tests (candida, yeast, mercury)

48 Urine tests (e.g., amino acid analysis for prescribing supplements, mercury testing) Dubious devices (e.g., Electronic-Allegro Sensations Test ) Physical exam procedures (muscle testing for allergies & nutrient deficiency, autoimmune disregulate testing, phrenology)

49 Imaging procedure Skin tests (e.g., patch test for mercury amalgam hypersensitivity) Questionnaires (e.g., nutrient deficiency) Internet testing Miscellaneous analyses (hair analysis, brain mapping, etc)

50 Just one example of how these tests can be misused can be seen by examining a frequently used test - hair analysis. Hair analysis involves sending a sample of the person s hair, taken from the back of the neck, to a laboratory for analysis.

51 Proponents claim that hair analysis is useful in evaluating the person s general state of nutrition and health, and in detecting a predisposition to disease. They also claim that hair analysis enables a doctor to determine if mineral deficiency or imbalance, or heavy metal pollutants in the body may cause the patient s symptoms - in this case, autism. These claims are simply false.

52 Scientific research has shown that, although hair analysis has limited value as a screening for heavy metal exposure, it is not reliable in evaluating nutritional status. Furthermore, most commercial hair analysis labs have not validated their techniques against standard reference materials.

53 The level of certain minerals in the hair can be affected by color, diameter, rate of growth, season, geographic location, age and gender - and normal ranges have not been established. Finally, use of a single hair analysis as the sole means for making a diagnosis violates all tenets of medical practice.

54 Table 1: Biologically-Based CAM Treatments TREATMENT A. Nutritional Vitamins PURPOSE Unspecified improvement in behavior RESEARCH/DATA TO SUPPORT 15 studies/ anecdotal reports Magnesium Given with B-6 Only anecdotal data Gluten, Casein-free diet Reduce GI symptoms Only anecdotal data Pancreatic enzymes Solve problem of loose stools None Colloidal silver Helps diarrhea None Super NuThera Improve taste of B-6/ magnesium No/Anecdotal. May increase irritability

55 TREATMENT Omega-3 fatty acids PURPOSE Improves digestion, heals leaky gut RESEARCH/DATA TO SUPPORT Dbl-blind studies/ Not helpful in ADHD Dimethylglycine(DMG) Increase eye contact/ decrease frustration Dbl-blind placebo control study/no effect Calcium For twitching in sleep None Aloe Vera Digestion/leaky gut None Flower of sulphur Improve digestion None Efalex oil/dha oil Food allergies/ Feingold diet Heal leaky gut/ improve vision, fine motor skill Remove additives = general improvement None Yes/Feingold diet disproven

56 TREATMENT PURPOSE B. Secretin Overall improvement in behavior C. Hyperbaric oxygen Theorizes that ASD is a viral brain infection. RESEARCH/DATA TO SUPPORT Yes/Phase III trials found no effect No research D. Fibroblast Growth Factor 2 E. Live Cell/Stem cell therapy Improve behavior; causes regression; used for seizures Keep body organs healthy No research No research F. Anti-fungal treatment/ Diflucon, Nizone, Nystatin G. Antibiotic Therapy Vancomycin Overgrowth of bacteria decrease aggression, hyperactivity Anecdotal Activate immune system/burst of words Anecdotal

57 TREATMENT H. Naltrexone (NTX) Therapy I. Immunoglobulin Therapy PURPOSE Block opiods functional improvements View ASD as autoimmune disease; improve behavior RESEARCH/DATA TO SUPPORT Open label trial Dbl-blind study/ need more research J. Detoxification of Remove from CNS; Chelation Therapy heavy metals improvement in behavior proven ineffective for lead poisoning. No research in Autism. K. EEG biofeedback Normalize brain waves No research L. Somatic Therapies Disorder of nervous system caused by spinal dislocation No research

58 TREATMENT M. Cranio-Sacral Therapy N. Traditional Chinese Medicine: acupuncture herbal medicine nutrition massage aromatherapy spinal manipulation lifestyle counseling PURPOSE Alter rhythmic movements of brain Heart, spleen, kidneys responsible for Autism; individual therapies to bring into balance. RESEARCH/DATA TO SUPPORT No research No research O. Melatonin Improves sleep No research P. Psychotropic medication Treat specific behavioral symptoms Few studies specific to Autism

59 Non-Biological Treatments Just as the biological treatments, non-biological therapies have also come into common use. Many of these therapies are now accepted as standard treatments for ASDs in spite of the fact that scientific support is at best minimal.

60 Table 2 lists some of the nonbiologically based interventions frequently proposed for ASD treatment. At times, there is overlap with the biological treatments. In addition, some information could only be found on web sites and not in scientific journals.

61 Table 2: Non-Biological Interventions TREATMENT A. SENSORY TREATMENTS 1. Sensory Integration Therapy PURPOSE Increase ability to process sensory info 2. Music Therapy Requires no verbal interaction. Seeks to effect changes in cognitive, physical, social & emotional skills RESEARCH/DATA TO SUPPORT No/ Anectodal single subject design No research in ASD

62 TREATMENT 3. Auditory Integration Training Berard Method Tomatis Method Samonas Method Rhythmic Entrainment PURPOSE Normalize hearing to allow brain to process auditory information more efficiently. 4. Aromatherapy Improve relaxation No RESEARCH/DATA TO SUPPORT No controlled studies reporting positive effects. 23 reporting positive results rely on parent report; three report no effect; two report mixed results. Amer Acad of Pediatrics & Amer Acad of Audiology warn no wellcontrolled studies. 5. Irlen Lenses Improve reading skills and depth perception. Improve learning skills. No/ Testimonials

63 TREATMENT PURPOSE RESEARCH/DATA TO SUPPORT 6. Ambient Lenses Improve awareness of body in space 7. Vision Therapy Correct eye coordination, perception, processing, focusing, tracking, & other vision difficulties No controlled studies No 8. Squeeze Machine Deep pressure stimulation; reduce tactile defensiveness No 9. Massage Therapy Reduce anxiety No controlled studies

64 TREATMENT PURPOSE RESEARCH/DATA TO SUPPORT B. RELATIONSHIP BASED THERAPIES 1. Psychoanalysis Focuses on maternal rejection as cause of ASD 2. Son Rise Options Cure autism; based on unconditional love and acceptance 3. FloorTime Therapy (child centered play) Emphasize relationship & engagement; child develops sense of self. No/Considered harmful No/Anecdotal testimonials No controlled studies 4. Relationship Development Intervention (RDI) Improve communication and social skills 5. Holding Therapy Increase parent-child bond No One study showed improvement;no control group

65 TREATMENT C. MOTOR THERAPIES 1. Doman/Delacato Patterning 2. Dance Movement Therapy 3. Facilitated Communication PURPOSE High levels of motor and sensory exercises to train nervous system and overcome handicap Reduce anxiety Persons with autism suffer from motor apraxia RESEARCH/DATA TO SUPPORT Research shows may be harmful for families No Yes, shown to be ineffective 4. Physical Exercise Decrease stress and selfstimulatory behaviors No

66 TREATMENT PURPOSE RESEARCH/DATA TO SUPPORT D. ANIMAL ASSISTED THERAPIES 1. Pet Visitation Fosters rapport & improve communication No 2. Social Dog Improve social interaction No 3. Therapeutic Horseback Riding Calming effect; improves balance, posture, mobility No 4. Hippo-therapy No 5. Dolphin Assisted Therapy (DAT) Improve speech & motor skills No

67 TREATMENT PURPOSE RESEARCH/DATA TO SUPPORT E. COMPUTER THERAPIES 1. Fast ForWord Improve auditory processing by slowing down sounds 2. Earobics Teaches auditory and phonological skills 3. Train Time Developed by Sp/L therapist; improve attention Only research from manufacturer None None 4. EEG Biofeedback Normalize brainwaves None 5. Interactive Metronome 6. ADAM Autistic Internet Interface Strengthens motor planning, sequence and timing Educational program for telepathic communication None None

68 TREATMENT F. MISCELLANEOUS PURPOSE 1. Miller Method Teach ASD children to follow directions. Elevated on board above ground. 2. Lindamood-Bell Multi-sensory approach to improve cognitive functioning. 3. AZ Method Uses videos for motivation to relate. 4.Spiritual Approach Belief that autism is a spiritual problem that can be healed through Torah. 5. Handle Institute Holistic approach for neurodevelopment and learning efficiency. 6. Epsom Salt Baths Improve sleep; decrease irritability; increase language RESEARCH/DATA TO SUPPORT None Manufacturer research only None None None No/Anecdotal

69 EVALUATING TREATMENTS It is important to remember that there is a very fine line to be drawn between controversial practices that merit consideration, review and study, and controversial practices that are hopelessly flawed.

70 Choosing who decides and what decision-making process is used may mean the difference between a stagnating and a vibrant field, the difference between current outcomes and better outcomes for children and families.

71 The question is: What process can parents use to avoid "dumping out the baby with the bath water"?

72 At this point, the suggestion is to use the results of the National Research Council (2001) position, which attempts to synthesize and integrate information on both controversial and not so controversial treatments. According to the NRC, over the past several years there has been increased interest in helping parents evaluate these pseudo scientific studies.

73 Jacobson, Foxx & Mulick (2005) published a comprehensive review, Controversial Therapies in Developmental Disabilities, which included ASD. Schriebman (2005) also reviewed the Science and Fiction of Autism. Both reviews stress the importance of consumer awareness of what constitutes scientific research and how to evaluate results and treatment.

74 There is no position paper, however, that can substitute for empirical study. Simpson (2004; 2005) reviewed issues and factors that relate to identifying and using effective practices with children with ASDs. In these reviews, 33 commonly used interventions for children with ASDs were evaluated & organized into five categories:

75 1) Interpersonal/Relationship-based 2) Skill-based 3) Cognitive 4) Physiological/Biological/Neurological 5) Other

76 In addition to descriptions, they also examined: reported outcomes qualifications of persons implementing the intervention how, where, when intervention is best carried out potential risks costs methods of evaluating effectiveness

77 Interventions & treatments examined were then graded as falling into one of four categories: 1) Scientifically-based 2) Promising practice 3) Practice having limited supporting info 4) Not recommended

78 Graded as Scientifically-based Practice: (Skill-based) Applied behavior analysis Discrete trial training (Cognitive) Learning Experiences: An Alternative Program for Preschoolers and Parents

79 Graded as Promising Practice: (Interpersonal) Play-oriented strategies (Skill-based) Picture Exchange Communication System Incidental teaching Structured teaching (e.g., TEACCH) Augmentative alternative communication Assistive technology Joint action routines

80 (Cognitive) Cognitive behavioral modification Cognitive learning strategies Social Stories Social decision-making strategies (Physiological) Sensory Integration

81 Graded as having Limited Supporting Information: (Interpersonal/Relationship-based) Gentle Teaching Options Method Floor Time Pet/Animal Therapy Relationship Development Intervention

82 (Skill-based) Van Dijk curricular approach FastForword (Cognitive) Cognitive scripts Cartooning Power Cards

83 (Physiological/Biological/Neurological) Scotopic sensitivity syndrome Irlen lenses Auditory Integration Training Megavitamin therapy Feingold diet Herb, mineral, other supplements

84 Not Recommended: (Interpersonal/Relationship-based) Holding therapy (Skill-based) Facilitated communication

85 Conclusions The field must move forward by identifying objectively verifiable intervention. The National Research Council has The National Research Council has identified a list of general characteristics:

86 Begin early intervention program as soon as an autism diagnosis is considered. Active engagement in an intensive instructional program for the equivalent of a full school day, including services that may be offered in different sites, five days a week, year-round.

87 Use of planned teaching opportunities organized around relatively brief periods of time for the youngest child. Sufficient amounts of adult attention in Sufficient amounts of adult attention in 1:1 and very small group instruction to meet individualized goals.

88 While these recommendations serve as a beginning, the field cannot progress without identification of objective interventions and treatments. Only one treatment meets all of these criteria: Applied Behavior Analysis

89 Evaluating Alternative Treatment Programs The basic principles of evaluation include approaching any new treatment with hopeful skepticism. The goal of any intervention should be to The goal of any intervention should be to improve the quality of life for the person with autism, and help the person become integrated into the community.

90 Debate over the use of various techniques is often reduced to superficial arguments over who is right and ethical, rather than who is the true advocate for the child with autism. The true advocate is the one who wants the child to become a fully functioning member of society.

91 Finally, it is important to be aware that most complementary alternative treatments have not been validated scientifically and often represent political positions.

92 Principles of Evaluating Treatment Programs (B.J. Freeman, 1997) 1) Approach any new treatment with hopeful skepticism. Remember, the goal of any treatment should be to help the individual with autism become a fully functioning member of society.

93 2) Beware of any program or technique that is touted as effective or desirable for every person with autism. 3) Beware of any program that thwarts individualization and potentially results in harmful program decisions. 4) Be aware that any treatment other than education represents one of several options open for a person with autism.

94 5) Be aware that treatment should always depend on individual assessment information that points to it as an appropriate choice for a particular child or person. 6) Be aware that no new treatment should be implemented until its proponents can specify assessment procedures necessary to determine whether it will be appropriate for the individual.

95 7) Be aware that debate over use of various techniques is often reduced to superficial arguments over who is right, moral and ethical, and who is a true advocate for the child/person with autism. 8) Be aware that often new treatments have not been validated scientifically.

96 Parents need to ask questions regarding any specific treatment. For example: What is the treatment's purpose & rationale? Is it logical? Is it based in theory that makes sense? Is there written information available?

97 Most of us respond better when given written information so that we can review it, as opposed to having to make a decision on the spot. It is also important to know what is involved for the child and the family.

98 Questions To Ask Regarding Specific Treatment (B. J. Freeman, 1997) 1) What is the treatment program s rationale and purpose? 2) Is there written information? 3) What is involved for child and family?

99 4) What is length of treatment, frequency of session, time and costs to the family? 5) Does the treatment focus on one skill or is it a comprehensive program? 6) Will the treatment result in harm to the child/person? 7) Is treatment developmentally appropriate?

100 8) What is the background and training experience of the staff? 9) Does the treatment staff allow input from the family? 10) Are assessment procedures specified, and is the program individualized for each child? 11) How will progress be measured?

101 12) How often will effectiveness of the intervention be evaluated? 13) Who will conduct the evaluation? 14) What criteria will be used to determine 14) What criteria will be used to determine if a treatment should be continued or abandoned?

102 15) What scientific evidence supports the effectiveness of the treatment program? 16) How will failure of the treatment affect the child and family? 17) How will treatment be integrated into the child s current program?

103 Do not become so infatuated with a given treatment that functional, behavioral, curriculum, vocational, life and social skills are ignored.

104 Educating Children with Autism (National Research Council 2001) 1. Characteristics of effective interventions There is general agreement that comprehensive programs are necessary - education in home, school & community remains the primary treatment for ASDs. Ethical considerations make research difficult.

105 2. Consensus of Current Programs Early intervention as soon as an ASD is suspected. Active engagement in an intensive Active engagement in an intensive instructional program for a full school day, a minimum of 5 days a week and full year programming.

106 Use of planned teaching opportunities organized around brief periods of time, e.g., minutes for a young child. Sufficient amounts of adult attention in Sufficient amounts of adult attention in 1:1 or very small group structure to meet individual goals.

107 Overall, effective programs are more similar than they are different in levels of organization, staffing, ongoing monitoring and use of certain techniques such as discrete trials, incidental teaching and structural teaching programs. However, philosophies of programs may differ significantly.

108 3. Recommendations Earliest possible start Minimum 25 hrs a week, 12 months a year Engagement in systematically planned and developmentally appropriate activities.

109 What constitutes hours will vary according to the child s age, developmental level, specific strengths and weaknesses, and family needs. Each child must receive sufficient individualized attention on a daily basis so that goals and objectives can be carried out effectively.

110 4. Curriculum Priorities of focus include: - functional spontaneous communication - social instructions delivered throughout the day in variety of settings - cognitive development - play skills - proactive approaches to behavior problems - ongoing interactions with typical peers, as long as it facilitates acquisition of goals

111 5. Personnel Preparation Specific training in ASDs is needed IDEA (2005) requires that scientifically IDEA (2005) requires that scientifically valid procedures be utilized in teaching.

112 Specific Educational Interventions Ongoing treatment in both social and communication areas in a general intervention setting. Given child's strengths and weaknesses the appropriate educational setting should include the following features:

113 - A small group setting with ample opportunities for individualized attention, an individualized approach, and small group work. - The availability of a communication specialist whose interest is in pragmatics and social skills training.

114 - Opportunities for social interaction and facilitation of social relationships in structured and supervised activities. - A concern for acquisition of real-life skills in addition to academic skills.

115 - Given the fact that the child excels in certain activities, it is be important to use these activities to improve social skills. - Social skills training should help the child - Social skills training should help the child learn to take the perspective of others, follow conversational interaction rules, and follow coherent and less one-sided goal directed behaviors.

116 - Willingness to adapt curriculum content requirements in order to flexibly provide opportunities for success and positive self-concept, and to foster an internalized investment in performance and progress. In light of this, a positive behavior support plan needs to be put in place that will work specifically on self-concept.

117 - The availability of a counselor who understands the child's difficulties, and someone for the child to talk to about having an ASD.

118 General Intervention Strategies Skills, concepts & appropriate procedures should be taught in explicit fashion using verbal teaching approaches, as the child's verbal speaking skills may be very high.

119 Specific problem solving strategies need to be taught for handling the student s troublesome situations. Training is also necessary for recognizing situations as problematic and applying learning strategies in discrepant situations.

120 Social awareness should be cultivated focusing on relevant aspects of given situations and pointing out irrelevancies. Generalization of learned strategies and social concepts should be instructed from the therapeutic setting to every day life.

121 Self-evaluation should be encouraged and awareness should be gained into which situations are easily managed and which are troublesome.

122 Adaptive skills intended to increase the child's self-sufficiency should be taught explicitly with no assumption that general explanations might suffice or that the child will be able to generalize.

123 The child should be instructed on how to identify a novel situation and resort to a pre-planned, well-rehearsed list of steps to be taken.

124 The link between specific frustration or anxiety producing experiences and negative feelings should be taught in a simplistic cause-effect relationship so that the child is able to gradually gain more measured insight into his/her feelings.

125 General Strategies for Communication Intervention & Social Skills Training Explicit verbal instructions on how to interpret other people's social behavior should be taught and exercised. The relationship between social situations and the child's behavior needs to be taught. Social stories and skill-streaming techniques may be useful in teaching specific social skills.

126 CONCLUSIONS As noted throughout, several factors have rendered ASDs vulnerable to etiological ideas and intervention approaches that make bold claims, yet are inconsistent with established scientific theories and unsupported by research.

127 Despite their absence of grounding in science, these theories and techniques are often passionately promoted by their advocates. There are several reasons for this: The diagnosis of ASD is typically made during the preschool years and is often devastating news for families.

128 Unlike most other physical or mental disabilities that affect a limited sphere of functioning or leave other areas intact, the effects of ASDs are pervasive, generally affecting all domains of functioning, particularly social.

129 Parents typically are highly motivated to attempt any promising treatment, rendering themselves vulnerable to promised "cures." The normal appearance of autistic children may lead parents, caregivers and teachers to become convinced that there must be a completely "normal or intact child lurking inside."

130 Thus, autism is fertile ground for complementary alternative treatments. The purpose here has been to review these alternative treatments and their use in autism, and to help parents develop guidelines for evaluating them.

131 Most of the treatments listed are a part of what we call pseudoscientific treatments with exaggerated claims of effectiveness that are well outside the range of established procedures. They often are based on implausible theories that cannot be proven false.

132 They tend to rely on anecdotal evidence and testimonials rather than controlled studies for support. When quantitative data are available, they are considered selectively, i.e., confirmatory results are highlighted, whereas unsupported results are either dismissed or ignored.

133 Finally, many of these treatments are often associated with individuals or organizations with a direct financial stake in the treatments. The more of these features that characterize a given theory or technique, the more scientifically suspect it becomes.

134 The alternative approaches listed are extremely heterogeneous in theory and approach. However, they all share the characteristic of possessing little or no scientific evidence of effectiveness. Even more distressing is that most of these treatments continue to be promoted even after controlled studies have clearly demonstrated their ineffectiveness.

135 The interventions reviewed may appear to give us little reason for hope in the treatment of autism. Fortunately, that is not the case. Developmental educational programs Developmental educational programs based on the principles of applied behavior analysis result in remarkable improvement for children with ASDs.

136 It is important for parents and professionals alike to be aware of how to evaluate current treatments being offered and how to determine the most appropriate treatment program for the child challenged by autism.

137 With an understanding of what is most appropriate for individuals challenged with Autism Spectrum Disorders, they can learn to become functioning members of society and we can focus on their unique abilities and not on their disabilities.

138 Remember: MULTIPLE ANECDOTES DO NOT EQUAL SCIENTIFIC EVIDENCE!!