By Kelly (McKinnon) Bermingham, MA, BCBA, author of The Group Experience and co-author of Social Skills Solutions: A Hands-on Manual
There is a long history of evidence and research indicating that early intervention is one of the most successful measures of autism spectrum disorder symptom reduction (ASD). In 2001, The National Research Council convened a panel of many of the most well-recognized national experts in the treatment of autism at the time. This panel was charged with integrating scientific literature and creating a framework for evaluating the scientific evidence concerning the effects and distinguishing features of the various treatments for autism. One of the significant recommendations for children on the autism spectrum is the need for early entry into an intervention program.
In a second Clinical Report of the American Academy of Pediatrics Council on Children With Disabilities, the report noted, “The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups.”
In the field of child development, the term “early intervention” refers to intensive therapeutic services provided for infants and young children (typically from the ages of under 2 to 5 or 6 years old) who have a delay in reaching developmental milestones before they enter kindergarten. “Intensive” means the hours provided to the child are significant and impactful. These programs are often also called EIBI programs, Early Intensive Behavioral Intervention. In the field of ABA, this is often referred to as a “Comprehensive ABA program” that assess for and seeks to teach and develop skills that are needed across all developmental areas. Additionally, according to the National Research Council, Committee on Educational Interventions for Children with Autism, the committee noted that research shows that early diagnosis of, and interventions for, autism are more likely to have major long-term positive effects on symptoms and later skills.
A young child’s brain is still forming, meaning it is more “plastic” or changeable than at older ages. Because of this plasticity, treatments have a better chance of being effective in the longer term. Early interventions not only give children the best start possible but also the best chance of developing to their full potential. Recent guidelines suggest starting an integrated developmental and behavioral intervention as soon as ASD is diagnosed or seriously suspected. ABA therapy programs should be designed for these crucial skills related to language and social communication deficits, including responsivity to social stimuli, which supports skills including imitation and joint attention as mentioned previously.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) was published in 2022. The DSM-5-TR is used to diagnose a person on the autism spectrum based on two primary domains.
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or historically:
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduce sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to the absence of interest in peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or historically:
- Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal/nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the same food every day).
- Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).
- Hyper- or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
As we can see, the core symptoms of autism are heavily related to language and social communication deficits. Conversely, we know that in neurotypically developing children, social and communication skills develop inherently. As these social and communication skills emerge, they are reinforced by people in their world and the environment they live in, further strengthening these skills. Let’s look at how these skills emerge and develop.
As young children age, they begin to look around and become aware of their surroundings. They smile or frown, or even cry based on what they see. They begin to imitate and respond to their environment based on what happens, or the consequences of their responses. They begin to point to ask for things or to show you things they see. They respond to the attention they receive when doing these things. During the first year of life, children start to develop close connections with their parents and other caregivers. They begin to observe, imitate, and show pleasure and displeasure. During the second year of life, children begin to notice other children and seek interactions with other children. They may begin to show pleasure with others, as well as conflict, and begin to recognize emotions in others. During the third year of life, children expand their play skills and explore more. They begin to develop friendships with those in their proximity and engage in common play actions. They begin to cooperate, imitate, and learn to accept compromise during conflict, with adult support. During the fourth year of life, conversation skills improve and become robust. Their social interactions with others advance through shared play and conversations. They begin to show support and help toward others.
Children may also interact with other children or more people in their environment. They may go to daycare or preschool, then on to kindergarten. In preschool, children are taught and reinforced to use language to communicate. They are taught to play, share, and play together cooperatively toward a common goal. They are taught to wait. They use their imitation skills to learn how to dance and sing and observe and learn new skills from other children. They move on to kindergarten and are taught even greater communication and social skills that include learning how to negotiate and play a friend’s choice. They learn how to regulate their feelings and behaviors. They learn these in a group experience. During the fifth year of life, children can more comfortably create and maintain friendships through common interests and play. They can engage in more complicated games that require more attention and are guided by rules. There is a wide variety of words and actions in play and interactions, and they can directly express concern and help. As they move on to an educational setting, they are ready and able to learn in a group format. They can follow along with an adult leading the group, follow the directions, and manage themselves around others.
Children diagnosed with autism are not likely to demonstrate these skills and they are not coming into contact with reinforcement. Going back to the diagnostic criteria and symptoms of autism, we see that deficits in social communication and social interaction across multiple contexts result in challenges with interacting with others in a social setting and these crucial milestones being missed.
A new study by Blacher et. Al, 2022 found that nearly one in six kids with autism are expelled from preschool and daycare. Many of them, in the sample, were expelled more often from a private than a public program. Most of the children were expelled due to their behavior which included temper tantrums, hitting, and yelling. The study found that often the teachers were not trained or credentialed and didn’t have the required courses in autism.
ABA is a science devoted to the understanding and improvement of human behavior. Applied behavior analysts focus on objectively defined behaviors of social significance; they intervene to improve the behaviors while demonstrating a reliable relationship between the interventions and the behavioral improvements. Most people think of ABA instruction being delivered in a 1:1 format. Concerns arise when a child transitions to a daycare or classroom setting. The child learning in the 1:1 format may not have the skills to learn alongside other children in a group format. Now we are back to the statistic of one in six kids with autism being expelled from preschool and daycare.
By providing early intervention in a group ABA-based format as soon as possible, we can better prepare the child with autism for group learning. If you think of the very best teacher, you ever had in school, the teacher likely employed ABA strategies, such as: including environmental arrangements, priming, using visual supports, reinforcement/reward strategies, and using first this. That teacher likely considered motivation and created activities that were interesting and motivating to you while you learned. That is using ABA in a group format.
For many children diagnosed with ASD, a comprehensive program would look across all of these developmental areas, identify what skills are missing, and then identifying appropriate teaching methods to teach those skills. This comprehensive program would likely be heavily based on play and natural environment teaching. It would include caregivers in the programming, as well as siblings, peers, and possibly other family members. It would include consultation with other therapies or providers the child may be receiving and coordinating care with those services. It would be intensive in the hours provided in the beginning, often 27-40 hours of ABA recommended according to research. This program would focus on teaching the child to be able to attend to, respond to, and participate in group environments as they prepare to attend daycare, preschool, or kindergarten. The ultimate goal of the ABA-based Early Intervention program should be to move from 1:1 therapy to a group learning experience, focusing on the developmental milestones described earlier, and allowing these skills to come into contact with reinforcement from other children.
References
American Academy of Ped American Academy of Pediatrics (2001). Policy Statement: The Pediatrician’s Role in the Diagnosis and Management of Autistic Spectrum Disorder in Children (RE060018) Pediatrics.
American Psychiatric Association (Ed.). (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR (Fifth edition, text revision). American Psychiatric Association Publishing.
California Legislative Blue-Ribbon Commission on Autism (2007). Report: An Opportunity to Achieve Real Change for Californians with Autism Spectrum Disorders. Sacramento, CA: The Legislative Office Building. Available online at: http://senweb03.sen.ca.gov/autism.
Blacher, J., & Eisenhower, A. (2023). Preschool and Child-Care Expulsion: Is it Elevated for Autistic Children? Exceptional Children, 89(2), 178-196. https://doi.org/10.1177/00144029221109234
Dawson, G., Toth, K., Abbott, R., Osterling, J., Munson, J., Estes, A., & Liaw, J. (2004). Early social attention impairments in autism: social orienting, joint attention, and attention to distress. Developmental Psychology, 40(2), 271–283. https://doi.org/10.1037/0012-1649.40.2.271
Myers, S.M., Johnson, C.P. & the American Academy of Pediatrics Council on Children With Disabilities, (2007). Management of children with autism spectrum disorders. Pediatrics. 120, 1162–1182.
National Research Council (2001). Educating Children with Autism, Committee on Educational Interventions for Children with Autism, Division of Behavioral and Social Sciences and Education, Washington, D.C.: National Academy Press.
The Group Experience. Printed in the United States of America Published by: Different Roads to Learning, Inc. 12 West 18th Street, Suite 3E New York, NY 10011 tel: 212.604.9637 | fax: 212.206.9329 www.difflearn.com
About the Author
Kelly (McKinnon) Bermingham has been working in the field for 27 years and has been a Board-Certified Behavior Analyst since 2003. She is an ESDM certified Therapist and a PEERS-certified therapist. Kelly wrote her first book, “Social Skills Solutions: A Hands-on Manual” in 2002. Kelly has written several blogs for Autism Speaks, been published in several journals, and co-authored a chapter in the textbook, “Rethinking Perception & Centering the Voices of Unique Individuals: Reframing Autism Inclusion in Praxis.” Kelly helped found a school for middle school & high school children on the autism spectrum and a sports league for children with autism. Kelly is part of The September 26th Project, creating safety awareness checklists and reminders for those on the autism spectrum and their families. She was an Expert Subject Matter for CASP’s recent Organizational Guidelines for ABA companies. Kelly provides training on The Group Experience to organizations based on this book.