1 Autism is a developmental disorder characterized by impairment in social interactions and communication and by restricted behavior, interests, and activities.

These three criteria are commonly referred to as a triad of impairments (Durand & Barlow, 2010; Wicks-Nelson & Israel, 2009). Autism affects 1-2 per 1,000 people, and about 6 in 1,000 people have an autistic spectrum disorder (ASD) (Newschaffer et al., 2007). About 40-55% of autistic people are mentally retarded, and often language abilities and IQ score are reliable predictors of future prognosis (Durand & Barlow, 2010). There is a distinction made between individuals functioning at a higher or lower level, and an IQ of about 70 is the defining score for these groups (Wicks-Nelson & Israel, 2009). The impairments in social integration included deficits in joint attention interactions, abnormal processing of social stimuli, and lack of understanding of social cues. Usually, gestures, such as pointing and eye contact, are used by a child in order to center his attention and that of his caregiver on an object in order to share an experience. Autistic children do not try to share experiences with their caregivers, or other children, and often appear aloof and disinterested. There is also impairment in recognizing and memorizing faces, and autistic children tend to focus on the mouth rather than the eyes. Communication impairment is another component of autism. 30% of children with autism never develop spoken language (Wicks-Nelson & Israel, 2009). For the other 70%, language development is often delayed and abnormal. Both echolalia, where the child echoes back what another person has said instead of creating their own sentence, and pronoun reversal are common (Durand & Barlow, 2010). In addition, autistic children often show deficits in pragmatics, and therefore misuse language. The third component of the triad of impairments is restricted, repetitive, and stereotyped behavior and interests. This criterion includes repetitive motor behaviors, obsession with parts of an object, preoccupation with restricted interests, and

2 inflexible adherence to routines or rituals. Children with autism may also compulsively collect articles or be overly absorbed in hobbies. Behavioral Treatment Options There are three treatment options for children with autism Applied Behavior Analysis (ABA), Treatment and Education of Autistic and Communication Handicapped Children (TEACCH), and the Denver Model. All three of these models have been used in empirical studies, and are appropriate for different treatment environments. This paper will mostly focus on ABA and TEACCH, with a little information on the Denver Model. Applied Behavior Analysis treatment has its basis in conditional learning. Interestingly, it is the only treatment for autism endorsed by the US Surgeon General (Wolfe & Neisworth, 2005). ABA is used to increase and maintain desirable behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations (Eikeseth, 2008; Myers & Johnson, 2007). There are four teaching procedures used in this treatment, which are based on the principles of operant conditioning (Granpeesheh, Tarbox, & Dixon, 2009; Love, Carr, Almason, & Petursdottir, 2009). Prompting is the presentation of cues or assistance in order to make a behavior occur when it otherwise would not. Fading is the systematic removal of a prompt, such that a desired behavior or skill continues to occur in its absence. Shaping is used to reinforce successive approximations toward a desired behavior. And chaining is used to teach a long sequence of behaviors that might be difficult for autistic children to learn the sequence is broken down into small behaviors, which are then prompted and reinforced, creating a chain of behaviors. In addition, there are multiple teaching formats used for ABA (Granpeesheh et al., 2007). Discrete trial training (DTT) is the most common, and is a structured teaching format where multiple

3 discrete opportunities are presented across the treatment in order to reinforce certain behaviors. DTT is useful in establishing learning readiness because it teaches foundation skills, including attention, compliance, imitation, and discrimination learning, among other skills (Myers & Johnson, 2007). Natural environment training (NET) is similar to DTT, but focuses on teaching skills in an environment that more closely resembles the typical daily activities of the child. In addition, the learning trials are initiated by the child, not the therapist. Functional behavior analysis is part of ABA, and is used to identify antecedents, consequences, and other environmental factors that maintain certain autistic behaviors. ABA therapists believe it is important to analyze why certain behaviors occur by identifying the ongoing sources of reinforcement that are normally produced by these behaviors (Granpeesheh et al., 2007). Sources of inadvertent reinforcement included caregiver attention, escape from nonpreferred activities, and access to preferred items, food, or activities. There are several important components of ABA, including parent involvement, intensive one-to-one therapy, early intervention, and individualized programming (Eikeseth, 2008; Love et al., 2009). One of the early proponents of ABA, Lovaas, believed that behavioral treatment could build complex behaviors, including language, and could also help suppress pathological behaviors, such as aggression and self-stimulatory behavior (Lovaas, 1987). In fact, Lovaas conducted one of the first influential empirical studies of ABA, and found that 47% of children who received this treatment achieved normal intellectual and educational functioning, while only 2% of the control group reached the normal level. TEACCH is a special education program for children with autism. It aims to address multiple problems of the disorder, including communication, cognition, perception, imitation, and motor skills (Eikeseth, 2008). TEACCH emphasizes teaching in multiple settings, including

4 the classroom and the home, and also proposes home programming, using parents as cotherapists. TEACCH consists of five main components, including a focus on structural treatment to teach children independent work skills; enhancement of visual processing; a communication system based on gesture, pictures, signs, or printed words; teaching pre-academic skills, including colors, numbers, shapes, drawing, writing, and assembly; and the involvement of parents as co-therapists (Eikeseth, 2008). In fact, the cornerstone of TEACCH is home programming, because it provides additional hours of intervention at a low cost and keeps parents involved for many years, serving as liaisons to new classrooms, placements, and agencies (Ozonoff & Catchart, 1998). The Denver model is another psycho-educational program for autistic children. It provides systematic instruction for these children, with a developmental play-based approach based on Paigets theory of cognitive development (Eikeseth, 2008). The Denver model is largely based on remediating key deficits in imitation, emotion sharing, theory of mind, and social perception (Myers & Johnson, 2007). These deficits are remediated through play, interpersonal relationships, and activities that foster symbolic thought and teach the importance of communication. Much of the Denver model is focused on the development of relationships, with the goal that autistic children will discover the value of positive interpersonal activities. Applied Behavioral Analysis (ABA) Much of the empirical research has focused on ABA, although there is some on TEACCH and the Denver Model as well. When looking at research on ABA treatment, it has been used in comparison to school services, eclectic treatment, and parent-directed treatment. Similarly, TEACCH has been used in comparison to both a control with no home programming and regular schooling. One of the largest limitations in the research on ABA treatment is that

5 most of the experiments do not use random assignment, but rather allow the parents to choose in which treatment group they would like their children placed. Cohen, Amerine-Dickens, and Smith (2006) conducted a replication of the 1987 Lovaas experiment. They compared ABA treatment with special education provided at local public schools for children with autism. This study was an attempt to fully replicate the Lovaas study, but in a community setting. The treatment group received 35-40 hours per week of one-to-one ABA treatment provided in a community setting for at least three years, with a focus on establishing foundational and spontaneous communication, peer play training, and inclusion in regular education classrooms. The comparison group received public community services for five hours per day, 3-5 days per week. Cohen, Amerine-Dickens, and Smith found that the ABA treatment group scored significantly higher on IQ at the follow-up; in fact, these participants showed a gain of 25 points. Another study also focused on ABA treatment, comparing its effects with that of eclectic intervention (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005). In this study, the treatment group received 25-30 hours per week of one-to-one ABA treatment in multiple settings, including home, school, and community. These children were presented with 50-100 learning opportunities per hour via discrete trial, incidental teaching, and other behavior analytic procedures. There were two comparison groups in this study. The first group included children enrolled in public school classrooms designed for children with autism, and received 25-30 hours per week of one-to-one or one-to-two eclectic intervention, including discrete trial, sensory integration therapy, and activities drawn from the TEACCH model. The second comparison group received 15 hours per week public early intervention in a group with a one-to-six ratio of teachers to children. After 14 months, the children receiving ABA treatment outperform

6 children in both comparison groups on virtually every follow-up measure used; these children had an IQ increase of 31 points. During the 14 months of treatment, the children in the ABA treatment group acquired skills in most domains at a rate that matched or exceeded the normal rate of one year of development per year of age; therefore, it is important that within this treatment learning rates exceed the normal rate for an extended period of time, allowing the autistic children to catch up with their counterparts. One of the reasons the authors propose for the decreased improvement of the children in the eclectic group as compared to the ABA group is that the eclectic therapy involved multiple transitions per day, which might cause problems for autistic children, as they do not respond well to changes in routine. Magiati, Charman, and Howlin (2007) compared parent-managed ABA treatment to autism-specific nursery school programs. In the parent-managed program, the families recruited therapists and managed the childs program. Often, they attended an initial workshop of 1-3 days, where they were taught various ABA techniques, including discrete trial training. The nursery school programs used an eclectic teaching style that emphasized structure, visual cues, individualized teaching, and close liaison with parents. TEACCH techniques were among the behavioral teaching methods used. At follow-up, there were no significant group differences in cognitive ability, language, play, or severity of autism. The authors did note, however, that children with initially higher cognitive and language functioning tended to make more progress, regardless of which intervention they received. Another replication of the 1987 Lovaas study was attempted by Smith, Groen, and Wynn (2000), who compared ABA treatment to parent training. The goal of the ABA treatment was to maximize the childrens intellectual, adaptive, and socioemotional functioning, thereby reducing their subsequent need for special emotional services. These children received ABA treatment for

7 30 hours per week for two to three years. At the beginning of the treatment, parents were asked to assist the therapist for five hours per week. The goal of the parent training group was to teach parents to use treatment approaches described in the Lovaas manual and assist them in using these approaches to help their children acquire skills. The families received two sessions per week of parent training for three to nine months in order to learn the techniques necessary to help their children. The children in the ABA treatment group outperformed the children in the parent training group at follow-up measures of intelligence, visual-spatial ability, language, and academic achievement, with an average gain of 16 IQ points. Another study also examined the effects of ABA treatment as compared to parentmanaged ABA treatment (Sallows & Graupner, 2005). In this study, the clinic-directed group received 40 hours per week of direct ABA treatment, as well as 6-10 hours per week of in-home therapist supervision. The parent-directed group received 32 hours per week of ABA treatment, with six hours per month of in-home therapist supervision. Although there was no significant difference in measures of intelligence, language functioning, adaptive functioning, socioemotional functioning, and autism symptoms between the two groups, in general there were significant posttest gains for IQ, language comprehension, and social and communication skills. The children in both groups gained an average of 25 IQ points. Eikeseth, Smith, Jahr, and Eldevik (2002, 2007) conducted two studies to observe the effects of ABA treatment on children older than age 4 over four years. Participants in the ABA treatment group received 28 hours per week of one-to-one ABA treatment, while participants in the eclectic group received 29 hours per week of one-to-one eclectic treatment, which incorporated elements from TEACCH, sensory-motor therapies, and ABA. In the ABA treatment group, instruction began in discrete trial formation, with the therapist devoting high

8 individualized attention to the child. As the therapy continued, focus shifted gradually to help children generalize skills to natural settings with regular peers, adjust to classroom routines and settings, and acquire new skills in these settings. After one year, the children in the ABA treatment group made significantly larger improvements compared to the eclectic treatment group, with a gain of 17 IQ points. At a second follow-up at year 3, the children who had received ABA treatment showed larger increases in scores, less severe aberrant behavior, and fewer social problems. At this stage, they had gained an average of 25 IQ points. Interestingly, the most gains in IQ and communication appeared between intake and year one, but the authors felt it was unclear as to whether this finding indicated that children derived maximal benefit on IQ and communication in the first year of intervention or whether the study had insufficient statistical power to detect gains on these measures after year one. The authors did note, however, that age at intake did not predict either treatment outcomes or gains in treatment, which shows that ABA treatment started after the child has reached age four can still be beneficial. Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) TEACCH-based home programming was compared to a control group that did not receive home programming but regularly attended a day treatment program to examine the impact of home programs of cognitive functioning in autistic children (Ozonoff & Cathcart, 1998). The explicit goal of the TEACCH group was to teach parents the principles underlying work with any autistic child, because typical methods of teaching, such as verbal explanation, demonstration, and modeling may not be successful due to the social, communicative, and imitative limitations of autism. Structured teaching, focusing on visual strengths used to teach more difficult skills like language and imitation, a schedule to help the child anticipate future events, and some sort of communication system were used to help prepare the child for entry

9 into the public school system. Children in the treatment group demonstrated significant improvement in developmental domains including imitation, perception, fine and gross motor skills, eye-hand coordination, and noverbal and verbal conceptual ability compared to the control group. In fact, in only four months, the treatment group made an average of 9.6 months of developmental gain. Panerai, Ferrante, and Zingale (2002) proposed that the TEACCH program might be more successful than other programs because it specifically addresses children with autism. They compared children in a control group who attended regular schools with support teachers to children who benefited from a TEACCH program. This program was based on three fundamental principles: the individual educational program, environmental adaptation, and alternative communication training. The experimental and control groups received the same amount of treatment, although the control group only received treatment solely in the morning, while the experimental groups treatment was distributed throughout the day. At follow-up, the children in the treatment group had statistically significant improvement in all of the developmental domains described above except for fine motor skills. Treatment Moderators Some research has been conducted on various moderators in the treatment of autism; three of these moderators are amount of treatment, family characteristics, and pretreatment IQ. One study looked at four factors pertaining to the treatment age of the child, number of hours of treatment per week, number of months of treatment, and total hours of treatment (Luiselli, Cannon, Ellis, & Sisson, 2000). They found that only the duration of treatment (number of months) was a predictor of improvement in communicative, cognitive, and socioemotional domains of a development rating scale. Interestingly, the age of the child was not as influential a

10 predictor of positive development as was the duration of treatment. The findings from this paper suggest that researchers should become more aware of the types of learning opportunities children are receiving outside of the formal treatment, as these other experiences might skew some of the data. Another moderator of treatment is family characteristics, although this topic is just beginning to receive research. Moes and Frea (2002) found that considering the family context during assessment and intervention planning for the autistic child contributed to the stability and durability of reductions in challenging behavior of the children. In addition, when therapists and parents designed a treatment plan together to be implemented in a home setting, there was significant improvement in development for the children who received treatment (Howard et al., 2005; Ozonoff & Cathcart, 1998). Pretreatment IQ and age have also been looked at as moderators, although there is still debate over whether or not they affect the treatment one study found that age did not affect treatment outcomes, while another found that children with initially higher cognitive functioning tended to make more progress, regardless of intervention group (Howard et al., 2005; Magiati et al., 2007; Rogers & Vismara, 2010). Comparing the results of these efficacy studies, it is clear that ABA treatment is effective for children with autism. At follow-up, the children who had received ABA treatment showed positive development in communication skills, an increase of at least 16 IQ points, and some were even able to attend regular schools without the help of an aide (Cohen et al., 2006; Eikeseth et al., 2002, 2007; Howard et al., 2005; Smith et al., 2000). Similarly, both of the papers that focused on TEACCH treatment also showed a significant increase in developmental domains for the children in the treatment group (Ozonoff & Cathcart, 1998; Panerai et al., 2002). He Denver model has not been studied in as much depth as these other two types of treatment, and therefore although introduced in this paper, was not focused on for empirical data. Interestingly, when

11 comparing these various studies, the outcome measures for the ABA treatment studies were different than those used in the TEACCH studies. The ABA research uses IQ, visual-spatial skills, language functioning, school placement, socioemotional functioning, adaptive functioning, and severity of autism as outcome measures. TEACCH research, on the other hand, uses the PEP-R measure, which looks at developmental domains including imitation, perception, fine and gross motor skills, eye-hand coordination, and noverbal and verbal conceptual ability. These differences could be a function of the date of the study, for the TEACCH research discussed in this paper was done prior to the ABA treatment research. These studies have several limitations, many of which span over most of the research. First of all, almost all of the studies are long term. While it is important to determine the effects of treatment on the long term for children with autism, there has not been much research on whether or not short term treatment is effective for this disorder. Another limitation is that most of these studies were actually quasiexperiments; few had true random assignment. Usually, the parents were allowed to choose which group they would like their children placed into, although some of the studies simply split participants into groups by placing the first half to respond to an advertisement in the treatment group and the second half in the comparison group. While quasiexperiments still have their merit, these studies do not have as much internal validity, and it is therefore more difficult to determine true causality. Family characteristics were discussed earlier as a possible treatment moderator, and therefore the dynamics of the family might have determined into which treatment group the parents placed their children. For example, if both of the parents of an autistic child worked, they might not be able to spend all of the time necessary with their child in order to provide effective treatment, and therefore might place their child in the comparison group, which could

12 relieve them of some treatment strain. While for the most part parent placement created equal groups without too many individual differences, random assignment would have eliminated any worry over individual differences between the two, or three, groups. Continuing with the discussion of parent involvement, some of the studies might not have taken outside learning experiences into consideration. While some of the research calls for home programming, where parents work with their children in addition to the official treatment they receive, others do not include parent involvement in their methods. Parents might try to work with their children at home, however, even if the treatment manual does not call for this work. While the parents might think that they are looking out for the best interest of their children, and therefore giving them as many opportunities for learning as possible, this additional work might confound the data. Another limitation of these studies is that there is still a lack of research on treatment moderators. As discussed above, the research on family characteristics as a moderator has just gotten underway, and therefore it is not yet clear exactly how much of a role the family plays in the effectiveness of the treatment for the autistic child. Similarly, there has been debate over the role of age and pretreatment IQ as treatment moderators. Some authors believe that these characteristics are predictors of successful therapy, while others state that they have no role whatsoever. Furthermore, some propose that while these characteristics have no direct interaction with the treatment, children who begin with higher pretreatment intelligence and language capabilities will show a larger increase at posttest, regardless of the type of treatment they received. The length of the follow-up period is another possible gap in this research. Often, there are significant differences between the treatment and comparison groups at follow-up, but it is unclear as to whether these differences continue, or if the groups end up with similar gains in

13 the long run. For example, Eikeseth et al. (2007) found that after one year children in the treatment group gained an average of 17 IQ points, but at the three year follow-up they had gained a total average of 25 points. As discussed earlier, the authors were uncertain as to whether initial gain in IQ points was always the case for ABA treatment, or whether the power of their study could not detect larger differences in the long-run. Conclusions and Future Directions There are multiple directions to be taken for future research on autism treatment. First of all, in general there is a need for more outcome research on the various types of treatment. As mentioned above, most of the current studies are long term research, and it is therefore important to determine the effectiveness of shorter-term treatment programs. While long term treatment is necessary for autistic children, as the disorder is permanent, the quicker a treatment begins to effect positive changes, the more effective it is considered. In addition, these outcome studies should focus on comparing the various types of treatment to each other. For example, the ABA treatment was studied in relation to school programs, eclectic treatment, and home programming. The TEACCH technique, on the other hand, was for the most part compared to home programming. It would be interesting to see more research on these techniques in relation to each other, as well as more research on some of the other therapies, like the Denver model, to determine their overall effectiveness. For the most part, researchers believe that treatment is most effective when started before the age of four years; after this age, children will not receive the same positive outcomes from the therapy. This concept has held for so long because of the idea of neural plasticity younger children are able to more quickly change neural pathways in their brains, which allows for them to make larger strides during treatment. While this concept is valid, it does not mean that

14 children over the age of four years with autism should not receive treatment. In fact, this idea suggests that children over four years of age should actually receive even more treatment than their younger counterparts, simply because it is more difficult for them to progress. In this regard, the Eikeseth et al. (2002, 2007) studies were important in that they showed that ABA treatment started with 7-year-old autistic children was just as effective as treatment started with 4-year-olds. Therefore, these authors were able to demonstrate that age is not a predictor of how well a child should fare in treatment, and therefore suggests that any child diagnosed with autism should begin treatment as soon as possible, but that treatment at any age is more beneficial that nothing. In addition, almost all of the research on autism treatment focuses on children there are very few studies on the effectiveness of treatment for autistic adults. Another area of possible research is treatment moderators. As mentioned above, there is debate over whether certain characteristics are predictors of success in treatment, and therefore more research is necessary to determine how these characteristics age, pretreatment IQ, family characteristics play into the treatment process. There could also be more research to examine the generalizability of interventions from a controlled research setting to more applied settings. For example, much research has shown that home programming leads to larger increases in IQ and language and adaptive abilities, and therefore it is important that therapists learn the most effective ways to bring parents into the treatment process. Both ABA treatment and TEACCH techniques have been proven effective in helping autistic children develop and reduce some of their impairments. A beneficial treatment option might be to integrate these two therapeutic techniques. ABA treatment is effective in increasing desirable behavior and decreasing maladaptive behavior, as well as teaching the child new skills. TEACCH focuses on communication, cognition, perception, imitation, and motor skills. If these

15 two techniques were integrated, then they would focus on all three parts of the triad of impairment, which should then lead to larger gains for the autistic child. An effective way to integrate these two techniques would be to increase home programming the parents should become an equal partner to the therapist, so that the child is constantly receiving learning opportunities, which give him more practice, eventually leading him to learn the correct behavior. The ABA treatment should be used as the main form of treatment, as it has the most empirical backing, but more techniques from TEACCH should be incorporated into the discrete trials. In addition, the parents should be familiar with all of the training techniques, allowing them to provide similar treatment at home as to what the child is receiving from the therapist.

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