Behavioral Therapy and Early Intervention for Improved Outcomes

‘Autism’ or ‘Autism Spectrum Disorder’ is a neurological condition characterised by impairments in social interaction, difficulty in communication, and repetitive or stereotypic interest or behaviour patterns that interfere significantly with the normal functioning of an individual. There has been a wide variety of treatment approaches on the road to practice, yet behaviour therapy remains to be one of the key foundations of psychological care and management for children or adults diagnosed with Autism Spectrum Disorders. New behavioural treatments (especially if applied during childhood) have shown great success in improving the social behaviour of individuals with autism, whereas in the past autism was seen as manageable illness with intensive support and structure.. Medical and mental health professionals can identify the signs of autism, help rule out other possible causes of the child’s behaviour, and refer the child to a specialist in behavioural therapy, most commonly applied behavioural analysis, the approach which has most proven success rates. Behavioural interventions and techniques are designed to reduce problem behaviours and teach functional alternative behaviours using the basic principles of behaviour change. These methods are based on behavioural/operant principles of learning; they involve examining the antecedents that elicit certain behaviour, along with the consequences that follow that behaviour, and then making adjustments in this chain to increase desired behaviours and/or decrease inappropriate ones. Behavioural interventions range from one-to-one discrete trial instruction to naturalistic approaches that focus only on communication, or on replacing maladaptive behaviours that are being used for communication. Behaviour modification techniques could thus be used effectively for regulating the behaviour patterns of young children in order to enhance their future life conditions.

CASE VIGNETTE

Ms. A, 1 year and 8 months old female child, was brought up to the clinical set-up with complaints of age inadequate speech and language, stubbornness/ temper tantrums, bruxism, inappropriate social interaction, stereotypic behaviour, inattention, lack of concentration, and impairments in motor functioning.

The child has been the second issue to a non-consanguineous union. Her 35 year old father is a farmer; and 28 year old mother is a homemaker. She has an elder sibling who is 12 year old. The child has been staying with her parents in a nuclear family set-up. There has been an unspecified history of mental illness in both paternal and maternal families of the child. The child has a normal birth history as reported. The age of her mother at the time of conception was around 26 years. Foetal movements were reported to be active and Regular Antenatal Check-ups were done. The mother had an episode of severe abdominal pain in the third trimester that consequently resulted in hospital admission. It was a Full Term LSCS . Immediate birth cry was present. Birth colour was reported to be normal, and birth weight was 2.500 Kg. The child was breast-fed and immunised as per schedule. Apart from a respiratory infection that occurred at the age of 3 months, there is no reported history of any significant physical illness during post-natal period. The motor development of the child was reported to be normal up to 7 months, but delays were observed since then. The child uttered her first word at the age of 1 year, but has not attained any progress in speech and language milestones yet. She could recognise her mother and responds to her name while being called; but did not engage in any kind of social interaction as appropriate to her age. She did not maintain eye -to-eye contact with others and appeared to be disinterested in the people and happenings around. She has been closely attached to her mother and depends on her for all activities of daily living. The child enjoyed playing, but prefers solitary play. Her span of attention was very less and she could not focus in play after a while.

CLINICAL EVALUATION/ IMPRESSION

On clinical evaluation conducted at the age of 1 year and 8 months, the child appeared to have age inappropriate development. As per the scores obtained in Vineland Social Maturity Scale (VSMS), she was reported to have a Social Quotient of 60 corresponding to a Social Age of 1 year. This implied that she was having mild retardation in social and adaptive functioning. As per the results of Developmental Screening Test (DST), she was found to have a Developmental Quotient of 65 corresponding to a Developmental Age of 1 year and 1 month. This showed that she was having mild delay in development as well. And the result of CARS indicates Moderate level of Autism. However, based on her clinical symptoms and preliminary assessment, she was provisionally diagnosed as having features of Autism Spectrum Disorder.

CASE CONCEPTUALIZATION

Based on the theory of behaviourism, the child was identified as having certain maladaptive behaviour patterns that had to be addressed immediately. Her stubbornness, temper tantrums, lack of attention, and stereotypic behaviours were taken as the core psychological patterns that induce a malfunctioning pattern. Principles of reinforcement and associative learning were taken as the mainstream apparatuses to address such maladaptive behaviours. Age of the child and immediate client goals were the major determinants of the therapeutic approach being suggested.

INTERVENTION PLAN

As the child was reported to have features of Autism Spectrum Disorder, a modern behaviourist approach was undertaken towards the management of the complaints including stubbornness/ temper tantrums, stereotypic behaviours, and other behavioural problems. Since she was below the age of 2 years, there were certain limitations in devising the intervention plan. However, treatment plan was structured according to the framework of behaviour therapy, solely based on the principles of secondary reinforcement being provided on the basis of a fixed ratio scale. ‘Prompting’ was adopted as the principal method of facilitating the therapy. Secondary Reinforcement refers to a situation where in a stimulus reinforces a behaviour after being previously associated with a primary reinforce or a stimulus that satisfies basic survival instinct such as food, drinks, and clothing. In this case, secondary reinforcements were provided if the child showed desirable behaviours, such as less stubbornness/ temper tantrums, or if she behaves in accordance with the simple instructions given by the therapist or her mother. Prompts (A prompt could be defined as a cue or hint that could be used to induce a particular behaviour or action) were given throughout in order to teach the child certain behavioural patterns (For example, she has to obey her mother if she wants to be carried in hand. The mother would not take her until and unless she stops crying and banging her head unnecessarily. In another instance, if the therapist prompts her to take objects and place it in the order of size, she should do it. Otherwise, the therapist would not clasp her hands in appreciation and as a sign of care). The intensity and modality of the prompts were regulated according to the behaviour of the child and variations in her responses. The nature of secondary reinforcement also varied according to the transgressions in the behavioural problems shown by the child. Immediate reinforcements were provided occasionally if the child engages in a highly desirable behaviour over time.

“Ms. A has been showing remarkable progress, says the therapist who has been treating her for a significant period of time. When she was presented to the clinical set-up for the first time, she appeared to be a totally detached child; but now, she has started interacting with others. It is quite pleasing to observe the minute improvements that she has been showing after each session” (Personal Communication, 2017). The therapist remarked that prompting and reinforcements provided on the basis of a fixed ratio scale have contributed much to her improvement. The major challenges were her age and associated physical disturbances, manifesting occasionally. But her family members, especially her mother has been very co-operative and ensured that all instructions given during the therapy sessions are being followed at home as well. Even though much time has been involved, a steady progress could be seen in her case record. The therapist also opined that this case could be taken as a good evidence for the effectiveness of behaviour modification techniques in treating autism among young children.

SUMMARY

Behaviour modification techniques based on the principles of Secondary reinforcement and Prompting could effectively used in the management and remedial care of young children who are having the features of Autism Spectrum Disorder. However, individual differences and socio-cultural contexts could mediate the results to a great extent. Nature of the therapeutic atmosphere, therapeutic alliance and familial support also play a vital role in determining the effectiveness of the therapy.