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14 Early Intervention in Autism

Geraldine Dawson and Julie Osterling

ONE OF THE most exciting recent achieve-ments in the field of autism is the ability torecognize this disorder at a very early age. Ayoung child with autism can now be recog-nized by difficulties in orienting to socialstimuli, impoverished social gaze, and im-

pairments in the areas of shared attentionand motor imitation (Curcio, 1978; Dawson& Adams, 1984; Dawson, Meltzoff, &Osterling, 1995; Mundy, Sigman, Ungerer,& Sherman, 1986; Osterling & Dawson,1994). These difficulties pertain to skillsusually evident during the first year of lifeand are likely to be apparent by at least 1year of age (Osterling & Dawson, 1994). Asof 1996, efforts are under way to developstandardized methods for very earlyidentification of children with autism(Lord, Storoschuk, Rutter, & Pickles, 1993).In the near future, it is likely that earlyintervention programs will focus on helpingyoung infants with autism and their parents.

Since the 1980s, we also have gained a better understanding of the tremendous het-erogeneity of the diagnostic category knownas pervasive developmental disorder (PDD)(American Psychiatric Association, 1994).We now recognize that autistic disorder is

but one subtype of the general category of PDD, this general category beingcharacterized by qualitative impairments insocial interaction

and communication. Other subtypes, such asAsperger syndrome, are being systematicallyidentified (American Psychiatric Association,1994). As our understanding of autismincreases, people with milder forms of autismare more likely to be identified. As a result,estimates of the prevalence of PDDs areclimbing. In 1996, it was estimated to beapproximately 15:10,000 people, three timesthe prevalence for autistic disorder. Schooladministrators are increasingly realizing thatmore resources are needed to serve youngchildren with autism and other PDDs. Fortu-nately, there now is a great deal known abouthow best to serve preschool-age children withautism and related disorders.

This chapter describes eight examples of model early intervention programs for childrenwith autism in the United States that have beenactive since the 1980s. These programs arereviewed with two goals in mind. The first is toaddress two questions related to theeffectiveness of early intervention programsfor children with autism 1: 1) Are the programseffective? and 2) Is effectiveness related to thetype or philosophy of the intervention or tocharacteristics of the child, such as IQ or verbal ability? This second question is

particularly pertinent to issues related tosecond-generation research (see Guralnick,1993, and Chapter 1). Based on the available

1It should be noted that the information on early intervention provided in this chapter is applicable to both children withautistic disorder and children with other diagnoses in the general category of PDD. Many of the intervention programs wereview involved both children with autistic disorder and those with PDD, not otherwise specified (see AmericanPsychiatric Association, 1994).


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outcome research, many children w h o receiveearly intervention make substantialdevelopmental gains and are able to beincluded in a general education classroom bythe time they enter elementary school.Furthermore, there exists little evidence thatthe philosophy of the program is critical for ensuring a positive outcome as long as certainfundamental program features are present.Finally, although it is likely that all childrenwith autism will benefit from earlyintervention, it remains unclear whether rateof progress is related to child characteristicssuch as IQ and language ability.

The second goal in reviewing these pro-grams is to describe the common elements of existing early intervention programs for chil-dren with autism. Despite having different

philosophical backgrounds and approaches,seasoned clinicians and researchers dealingwith children with autism are shaped by thecommon experience of working with thesechildren. Out of this common experience havecome basic shared beliefs and methods for helping children with autism. Unless oneapproach is eventually found to be much moreeffective than another, these shared beliefsand methods may come to be considered themost basic and essential features of an

early intervention program for children withautism.

EIGHT MODEL PROGRAMS:APPROACHES AND EFFECTIVENESS

The eight preschool programs described in thischapter have published detailed descriptions of their philosophies and approaches. In addition,comprehensive intake and outcome data areavailable for most programs. A brief description of each of the programs is provided first. Next, the characteristics of the childrenentering the programs are reviewed, followed

by a summary of the outcome data.

Program DescriptionsTable 1 provides an overview of some of the

basic program fea tures. A more detailed de-scription of each program follows.

Douglass Developmental Disabilities CenterThe Douglass Developmental DisabilitiesCenter program (Rutgers University; Han-dleman & Harris, 1994; Harris, Handleman,Kristoff, Bass, & Gordon, 1990) is based on

principles of applied behavior analysis and behavior intervention approaches. Three dif-ferent types of classrooms comprise the pro-gram: the "prep" class, the small group class,and the integrated classroom, with children

Table 1. Program characteristics

Program Program emphasis Hoursper

week a

Inclusion Staff/childratio

1-to-1 work

Douglass Developmentally sequenced 25 After 12 years 1:1 to 4:6:8 b YesHealth Sciences Developmental/social-pragmatic 22.5 No 3:6 YesLEAP Typical preschoolprogramming 15 Yes 3:6:10 b YesMay Developmentally sequenced 30 After 12 years 1:1 to 3:6:7 b YesPrinceton Individualized behavior programs 27.5 No 1:5 Yes

TEACCH Structured teaching Varies Varies Varies YesWalden Incidental teaching 30 Yes 1:3 Yes

Young Autism Discrete trial training 40 Later intreatment

1:1 Yes

a Does not include hours of intervention received at home, except for the Young Autism Program, which provides servicesat child's home.

bRatios are given in order as follows: number of staff/number of children with autism/number of typically developingchildren.


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typically progressing over approximately a 3-year period from the segregated, highlystructured prep classroom to an integrated

preschool classroom. The prep classroom provides intensive one-to-one discrete trialtraining, based largely on Lovaas' model of instruction (see Young Autism Program) and includes both classroom and in-home in-struction. The small group classroom maintainsa 2:1 childteacher ratio and focuses

particularly on skills that will be needed tofunction in the integrated classroom. The in-tegrated classroom is based in part on Strain'sLEAP model (described below) and serveschildren with autism and those developingtypically. A staff member visits each family athome bimonthly. In addition, parents are in-vited to a monthly or bimonthly "clinic"meeting at which all involved personneldiscuss the child's progress and areas of concern. The program also offers parent and sibling support groups.

Health Sciences Center The Health SciencesCenter program (University of Colorado;Rogers & DiLalla, 1991; Rogers, Herbison,Lewis, Patone, & Reis, 1986; Rogers & Lewis,1989) serves children with autism and PDD aswell as children with varied behavior disorders.The curriculum is based on developmental

principles and emphasizes play as an importantmedium through which socioemotional,communicative, and cognitive development arefacilitated. The program also emphasizeseliciting positive affect within the context of social interaction to increase children's attentionto others and motivation to engage inrelationships. Social relationships are facilitated

by assigning each child a primary teacher, byfostering close proximity to and imitation of

peers, and by modeling and prompting specificsocial behaviors. For children who comprehend complex spoken language, teachers also provideverbal explanations in order to help the children

better understand other people's emotions, behavior, and perspectives. When appropriate ,children are provided with occupationaltherapy, individual psychotherapy, or both.

Parents in the program are offered 1-hour weekly consultation with a child psychologist

or psychiatrist during which they can discusstheir child's development and behavior and other areas of concern. Monthly parent sup-

port group meetings are offered, and parentsare encouraged to observe and participate inthe classroom as frequently as they wish.

Learning Experiences . . . An Alternative Program for Preschoolers and Parents (LEAP)The LEAP program (Hoyson, Jamieson, &Strain, 1984; Strain & Cordisco, 1994) has twocomponents: an integrated preschool program(which includes both typically developingchildren and children with autism) and a

behavior skills training program for parents.The curriculum emphasizes a blend of typical

preschool activities (e.g., activity areas and weekly themes) and activities specificallydesigned for children with autism. The

primary goal of the curriculum is to exposechildren with autism to typical preschoolactivities as much as possible and to adapt thetypical curriculum for the children with autismonly when needed. Independent play skills and social interaction are facilitated by using peer models and by prompting, fading, and reinforcing target behaviors.

The behavior skills training programteaches parents techniques for managing their child's behavior and teaching new skills. Afamily service coordinator works with thefamily to teach specific target behaviors in anatural context, such as the home or com-munity. Families are also invited to attend amonthly parent support group. May Institute The May Institute (Boston;

Anderson, Avery, Dipietro, Edwards, & Chris-tian, 1987; Anderson, Campbell, & Cannon,1994) offers a developmentally sequenced

program based on principles of applied behavior analysis and behavior intervention approaches.When children enter the program, they and their families receive intensive (15 hours per week) in-home training for a period of 6 months. Duringthis period, the in-home therapist and parents

provide one-to-one instruction focusing on basic skills such as play, self-care, language,and the reduction of problem behaviors. After the children complete the home-based treatment, or concurrent with this treatment,


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they attend one of the Institute's two preschool programs, the "Step 1" classroomor the integrated classroom. Most childrenattend the Step 1 class for approximately 1year, where basic classroom skills such asfollowing instructions, imitation, and working in groups are taught. The Step 1classroom contains only children with autism,and instruction usually takes place in highlystructured, teacher-directed small groups. Theintegrated classroom includes children withdevelopmental disabilities (mostly autism) aswell as typically developing children. The cur-riculum focuses on teaching skills that thechildren will need in a general kindergartenclassroom.

Families are visited at home by their child's

service coordinator once a month. Duringthese visits, the parents and service coordi-nator discuss the child's progress and parents'areas of concern. Once a month, the programoffers parent support groups and educationaldiscussion sessions led by program staff. TheMay Institute also provides other services,such as respite care for families and outsidereferral information.

Princeton Child Development Institute ThePrinceton Child Development Institute program

(Princeton University; Fenske, Zalenski, Krantz,& McClannahan, 1985; McClannahan & Krantz,1994) is based on principles of applied behavior analysis and behavior intervention approaches and serves only children with autism. Each child isfirst evaluated so that a set of individualized

behavior "programs" can be prescribed. Mostchildren's first set of behavior programs targets

basic skills such as following simple instructions,motor and verbal imitation, toileting, and matching skills. Over the course of the school

day, the children work in different activity areasand rooms and with different staff members inorder to promote genera l iza t ion of r e q u i r e d skills. Children are taught to use

picture schedules to assist them with the manytransitions they are required to make during theday. Picture schedules also assist the children inlearning to initiate activities, make choices, and

become more independent. Periodically, thechildren's progress is assessed and specific goals

are revised. Twice a month, each family isvisited at home by a home programmer who helpsthe family implement behavior programs that thechild has successfully achieved at school inorder to maximize generalization of skills fromschool to home. Parent meetings are held regularly at the school.

Treatment and Education of Autistic and Communication-Handicapped Children(TEACCH) The TEACCH curriculum(University of North Carolina at Chapel Hill;Lord & Schopler, 1994) emphasizes two basic

principles: structuring the environment to promote skill acquisi tion and facilita tingindependence at all levels of functioning.Children are taught new, developmentallyappropriate skills in a highly structured

teaching environment in which one-to-oneinstruction is offered. Once a skill is estab-lished, the children are taught to use the skill ina less structured environment with lesssupport from adults so that they can graduallygain increasing independence. Independenceis also fostered by the structured teachingenvironment, which relies heavily on visualcues such as the use of "start and finish

boxes" to signal the beginning and end of activities. The TEACCH program, which

strives to provide the least restrictive teachingenvironment, is used throughout NorthCarolina in a variety of different schoolsettings and in a variety of different ways.Consultants visit each child's classroom on aregular basis to provide information on how toadapt each classroom to the needs of each child and his or her family.

Walden Preschool The Walden Preschoolcurriculum (Emory University School of Medicine; McGee, Daly, & Jacobs, 1994) fo-

cuses on language and social developmentusing an incidental teaching method (Hart &Risley, 1975; Kaiser, Yoder, & Keetz, 1992), the

basic tenets of which involve giving the child opportunities to practice a skill duringinteractions between an adult and child thatspontaneously arise in natural contexts such asfree play. The classroom consists of a number of "teaching zones" (usually four) that are


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organized around different teaching goals and are designed to naturally attract children todesired activities and materials. Each teachingzone is staffed by at least one teacher whoadapts the teaching goals to each child'sdevelopmental level and facilitates theacquisition of target skills. Children are free tomove from one zone to another; one teacher's

primary responsibility is to help children maketransitions from one zone to another. The

preschool classroom includes children withautism and typically developing children.Parents are offered a number of options for how they would like to maintain contact withthe school, which range from home visits toregular meetings with the teaching staff.

Young Autism Program The Young Autism

Program (University of California at Los Angeles[UCLA]; Lovaas, 1987; Lovaas, Smith, &McEachin, 1989; McEachin, Smith-Tristram, &Lovaas, 1993) is based on principles of applied

behavior analysis and behavior interventionstrategies. In the initial phases of the program,children receive intensive one-to-one discrete trialtraining for 40 hours per week. Parents are trained to use the treatment procedures so that the inter-vention can take place during most of the child'swaking hours. In the first year, emphasis is placed

on reducing self-stimulatory and aggressive behaviors, building compliance, imitation, and appropriate toy play. The second year emphasizesexpressive and abstract language and interactive

play with peers. The children also are taught howto function in a preschool group by enrolling themin a preschool program (in a general education

preschool, if possible). The third year emphasizesappropriate expression of emotion, preacademictasks, and observational learning. Aggressive and self-stimulatory behaviors are handled by ignoring,time-out, shaping, and (as a last resort) delivery of a loud "no" or slap on the thigh.

Characteristics of ChildrenEnrolled in the ProgramsTable 2 provides an overview of the charac-teristics of children who participated in the

preschool programs. Although the assessmentmeasures varied across the programs, virtuallyall programs administered on a regular basissome form of standardized assessmentdesigned to measure children's verbal and nonverbal abilities, autistic symptoms, and adaptive behaviors. Some of the programs alsoassessed other developmental domains, such as

play, motor, and social skills.The average age of the children entering the

programs was 3.5-4 years. This is the averageage at which an initial diagnosis of autism isfirst made (Siegel, Pliner, Eschler, & Elliott,1988). Thus, it is likely that the children in thisreview began treatment at an age typical for most children in the United States. Thechildren in the Young Autism Program atUCLA, however, were typically younger thanthe children in the other programs; theaverage age at intake for Lovaas' program was2 years 8 months (McEachin et al., 1993),whereas the average age for the children in theother programs was 3 years 9 months.

Table 2. Characteristics of children enrolled in the programsProgram No. of children Mean age (months)

(range) Full-ScaleIQ(range)

Diagnosis

Douglass 36 50(30-62) 61 (36105) Autism Health Sciences 49 46 70 (nonverbal) Autism or PDD LEAP 48 43 (3064) 61 (6119) Autism or PDD May 42 47 (3662) 49 (37-71) a Autism or PDD Princeton 32 43 (3058) 57 (3683) Autism Walden 27 44 (3066) 57 (2991) Autism

Young Autism 19 32 53 (3082) Autisma IQ available for only 10 children.


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At intake, the typical Full-Scale IQ score for children in the programs fell in the mid-50s,ranging from 49 to 70 on average, with most

programs reporting that a small number of their children were not testable at intake. This range of functioning is consistent with that of the general

population of preschool children with autism. The beginning IQ levels of the children in different programs were fairly similar. Most programsused the Stanford-Binet Scale (Terman & Merrill,1960) to assess Full-Scale IQ, but some programsused measures that have a stronger nonverballoading (e.g., Merrill-Palmer, McCarthy scales).Because children with autism tend to perform

better on non-verbal tasks, it is difficult to comparethe intake IQs of children across the different pro-grams. For instance, at intake, the children atthe Health Sciences Center at the University of Colorado had an average IQ of 70, which ishigher than the average IQs of the other pro-grams. However, IQ in this program was mea-sured using primarily nonverbal IQ tests.

Approximately half the programs accepted children with autistic disorder or PPD, nototherwise specified, whereas the other half admitted only children with a diagnosis of autism. Most programs used Diagnostic and Statistical Manual of Mental Disorders ( DSM -III-R) criteria developed by the AmericanPsychiatric Association (1994) in their initialdiagnostic evaluations, and some programsused the Childhood Autism Rating Scale(Schopler, Reichler,. DeVellis, & Daly, 1980) asan additional component in the d iagnosis.

Child OutcomeOutcome data are available for approximately150 children who completed one of the

programs. All programs have been evaluated using outcome data, but program directors

described their children's outcomes in differentways. Some primarily emphasized the types of

post-preschool placements achieved by their children, whereas others also described specific developmental gains made by their children. A summary of these data is provided in Table 3. Of the eight programs, six provided

placement data for their graduating children. Asubstantial number of children in the programs

were able to function in a general educationsetting. However, the nature of the generaleducation placement and the extent to whichspecial support services were needed to main-tain a successful placement varied consider-ably.

The type of support services children re-ceived when they were placed in a generaleducation setting also varied considerably.Unfortunately, there often was little detailed information regarding the extent and type of support children received. It is also importantto keep in mind that policies of a particular school district likely influenced the extent towhich a given child was able to be included in ageneral education classroom. Consequently,children with equal levels of abilities may haveachieved different placement outcomes based onwhere they lived. For these reasons, it is not

possible to meaningfully compare the different programs' effectiveness based on the placementdata.

Six of the eight programs characterized child outcome in terms of specific developmentalgains made while in the program. The pro-grams described the developmental gains of thechildren in a variety of ways (e.g., IQ scores,developmental scores on standardized tests,observational measures taken in the class-room). Comparing the outcomes of different

programs is problematic because of thediversity of the measures used.

General Conclusions Regardingthe Effectiveness of Early InterventionAlthough a direct comparison of the effec-tiveness of the different programs is not

possible , combining information across pro-grams provides a general view of the overall

progress of the 150 children who received

early intervention. We can conclude that, de-spite somewhat diverse intervention strategiesand philosophical approaches, all of the pro-grams were quite effective in fostering positiveschool placements, significant developmentalgains, or both for a substantial percentage of their students. Of the six programs that re-

ported placement data, four reported thatapproximately 50% of children were able to be


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Table 3. Child outcomes

Program Placement outcomes Developmental gains

Douglass 3/21 children "fully integrated"16/21 in classes for children with neurological

communication disabilities

A nearly 19-point increase in IQ after 1year of treatment

Health Sciences Significant increases in language,cognitive, social, and motor skills

Doubling of developmental rate inseveral areas, reaching typical rates

Significant increases in language,cognitive, and motor skills

Doubling of developmental rate inseveral areas

LEAP Approximately 50% in "regular education classes"

May 14/26 children "mainstreamed," but many required"specialized supports" such as an aide

Princeton 12/24 children in "public schools" Nonverbal children identified by 3years gained an average of 22-24 IQpoints by 7 years of age

TEACCH Those identified by 4 years gained 15-19 IQ points by 9 years of age

Walden 12/14 children "fully mainstreamed" Observational measures indicated thatlanguage use tripled

Young Autism 9/19 children attended general first-grade classes8/19 children in classes for children with aphasia47% of original 19 children in general classes at

13 years of age

By first grade, children gained anaverage of 20 IQ points, with 12 of 19 falling in the average range


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integrated into a general classroom by the end of the intervention. When outcome was assess-ed in terms of IQ, it was found that childrenmade, on average, an IQ gain of approximately20 points. Investigators did not report whether a positive response to intervention was related to specific child characteristics, such as IQ or language ability. It should be noted, however,that most children participating in the pro-gram scored as having some level of mentalretardation (IQ less than 70) at the beginningof intervention. Thus, despite having autismand considerable cognitive delay, approxi-mately half of the children responded very

positively to early intervention, and all or atleast most children reportedly made significantgains.

To what extent can the reported gains beattributed to early intervention? Unfortunately,only one program published data on a controlgroup of children with autism who did not

participate in the early intervention program(Lovaas, 1987; Lovaas et al., 1989), and, todate, there have been no true experimentalstudies that would require, at minimum, randomassignment to different intervention groups and outcome assessments conducted by peoplenaive with regard to intervention status.Despite its methodological limitations (e.g.,lack of random assignment to intervention vs.control group), the Lovaas study is very en-couraging, especially in light of the 1993findings that the positive effects of thisintervention have been maintained through theelementary school years (McEachin et al., 1993).More specific answers to questions such aswhether one intervention approach is moreeffective than another and what is the optimalintensity of intervention will have to await the

next generation of intervention research.

COMMON ELEMENTS OF THEPROGRAMS: THE "TRIED AND TRUE"

This section describes several elements of early intervention for children with autismthat are common to virtually all of the pro-grams reviewed. Despite considerable differ-

ences in the philosophical approaches of the programs, these are the elements tha t most program directors believe are essential, al-though their methods for addressing each el-ement vary. The assumption is that, to a largeextent, these elements emerged from manyhours of working with the unique challengesthat a child with autism presents. In thissense, they can be considered the "tried and true" features of early intervention for children with autism; they are unlikely to re-flect an idiosyncratic viewpoint or one inves-tigator's philosophical attitude. Therefore,these are the elements that parents should reasonably expect a school system to providefor their child.

Element One: Curriculum ContentThe curricula reviewed previously typicallyemphasize five basic skill domains. The firstskill domain focuses on the ability to attend toelements of the environment that are essential for learning, especially to other people, and to com-

ply with teaching demands. As was described previously, autism is characterized by a failure toselectively attend to social stimuli, includingfacial expressions, gestures, and speech(Dawson et al., 1995). Thus, not only does the

child with autism have difficulty interpretingsocial stimuli, he or she is failing to attend tothem in the first place. This is an especiallydifficult problem because knowledge of theworld often comes directly from other people.Therefore, the first and often most difficult skillto teach the young child with autism is to payattention to other people. Children with autismalso may have difficulty shifting their attentionfrom one stimulus to another (Courchesne et al.,1994), attending to more than one stimulus at a

time (Koegel & Schreibman, 1977), and sharingattention states with others (Mundy et al., 1986).Many programs address these attention pro-

blems as well (Lord & Schopler, 1994; Lovaas,1987; Rogers & DiLalla, 1991). However, the

programs vary in .how they increase attentionskills. The Young Autism Program emphasizesdiscrete trial learning, whereas the WaldenPreschool uses incidental teaching strategies in


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which staff structure the environment to in-crease the child's chance of attending to appro-

priate stimuli.The second skill domain is the ability to imitate

others, including both verbal imitation and motor imitation. Verbal imitation often is easier for children with autism; some of these childrenspontaneously echo what others say to them. Acouple of decades ago, echolalia was considered

pathological, and teachers would discourageecholalic speech. Based on careful longitudinalresearch on the development of language inautism, we now know that echolalia is a criticalfirst phase of early language acquisition for many of these children (Prizant & Wetherby,1989).

In contrast to verbal imitation, most childrenwith autism fail to spontaneously imitate the mo-tor actions of others (Curcio, 1978; Dawson &Adams, 1984). Motor imitation is an especiallyimportant skill because it is a fundamental mech-anism for learning. Social skills, in particular, areoften learned by imitating others. From a develop-mental perspective, imitation is intimately linked to the development of representational thought(Piaget, 1962). Furthermore, imitation servesmany social functions, including providing acontext of mutuality in which communication and empathy may develop (Dawson & Lewy, 1989;Meltzoff & Gopnik, 1993; Uzgiris, 1981).Approaches to teaching imitation range fromdirect teaching via operant conditioning methods(Lovaas, 1987) to facilitating spontaneous imita-tion via structured social play (Rogers & DiLalla,1991).

The third skill domain is the ability to comprehend and use language (see Chapter 16). Aswith imitation, approaches to facilitating languageacquisition differ. All approaches, however,recognize the motivational issues involved inlanguage acquisition in autism (Koegel &Mentis, 1985). Children with autism typically arenot motivated to communicate for the sake of sharing information and experiences (Tager-Flusberg, 1989, 1993). The child must be "tempt-ed " to communicate by capitalizing on the naturaldesires and preferences of the child (Koegel &Johnson, 1989). Most early intervention strat-egies involve providing immediate and

rewarding responses to the child's smallestattempt to communicate, be it a glance, a vocal-ization, or the slightest body movement (McGeeet al., 1994). In this way, the child with autism isable to achieve one of the most important and challenging early goals: grasping the concept of communicative intent. Furthermore, it is recog-nized that the child with autism needs earlyexposure to a range of communicative modal-ities, including the use of visual symbols, gest-ures, written word, and speech (Prizant &Wetherby, 1989).

The fourth skill domain is the ability to playappropriately with toys. It is widely known thatchildren with autism play with toys in idio-syncratic, repetitive ways (Jarrod, Boucher, &Smith, 1993) and that their imaginary play isoften severely delayed or absent (Riguet, Taylor,Benaroya, & Klein, 1981; Ungerer & Sigman,1981). Intervention strategies for facilitating playdevelopment focus on increasing the child'sability to use toys in functionally appropriateways and promoting the use of symbolic play.Research has shown that children with autismoften are capable of functional and symbolic playwhen specific prompts are used (Lewis &Boucher, 1988). Most intervention strategiescapitalize on this fact by using physical and verbal

prompts to facilitate toy play.Finally, the fifth skill domain is the ability to

socially interact with others, especially with peers(see Chapter 23). Interactive play with peers oftenis considered a more advanced skill domain for young children with autism. Social skills areinherently complex and involve the core impair-ments of children with autism. Some programs

begin by teaching specific skills, such as turntaking and sharing, in the context of adult-child interaction and then systematically generalizethese skills to child-child interactions. Many

programs also recognize the effectiveness of usingtypically developing peers as facilitators of social

behavior (Strain & Cordisco; 1994).

Element Two: Need for Highly SupportiveTeaching Environments and GeneralizationStrategiesIn most programs, core skills first are established in highly supportive teaching environments and


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then are systematically generalized to more complex, natural environments. Core skills refer tothose skill domains that are inherently part of theautistic syndrome and are critical for the acqui-sition of knowledge (also referred to as "pivotalskills" by Koegel & Koegel, 1988). Not surp-risingly, these are the skills listed previously,which are the focus of most curricula: attentionand compliance, imitation, communication, appro-

priate toy play, and social skills. In virtually all programs, these skills are first taught in highlystructured contexts in which the child interactsdirectly with a trained therapist or teacher in anenvironment that minimizes distraction and max-imizes attention to specific stimuli. Features of theenvironment that serve to maximize attention torelevant stimuli include repetition, predictability,and salience (e.g., by increasing the intensity of thestimuli, by placing the stimulus directly in thechild's visual field). Furthermore, explicit supportfor a newly acquired behavior is provided by ano-ther person (e.g., by modeling the behavior or by

providing direct physical guidance or prompts). Itis important to note that all programs have a verylow staff-to-child ratio in order to provide this kind of intensive teaching. Ratios typically are 1:1 or 1:2, especially during the first part of the inter-vention.

At first glance, advocating such an intensive,highly supportive teaching environment for child-ren with autism may seem counterproductive,especially because it is now known that manychildren with developmental disabilities are quitecapable of gaining skills in more complex environ-ments that typically involve small or even largegroups of children. However, this may not be thecase for a child with autism. We speculate thatchildren with autism have such severe information-

processing impairments that they have difficultyattending to and encoding critical information,such as gestures, language, and facial expressions,when such information is presented in a highlycomplex environment. The child with autismappears to need what has been referred to as an augmented scaffold (Klinger &, Dawson, 1992).Scaffolding, a term long used in the developmental

psychology literature, refers to the processwhereby parents and teachers naturally help tostructure the child's environment to maximize

attention to relevant information for learning and success in learning.

An important issue that must be addressed,however, is the fact that children with autism oftenshow large discrepancies between their perfor-mance levels in highly supportive versus morenatural, complex environments. When specific

prompts and familiar cues are available, the child with autism is capable of much higher levels of

performance, even in skill domains that are consid-ered core impairments in autism, such as toy play(Lewis & Boucher, 1988) and social responsive-ness (Dawson & Galpert, 1990;Klinger & Dawson,1992). Indeed, increasing spontaneous perform-ance of previously learned behaviors in complex,natural environments is one of the major hurdlesfaced by those working with individuals withautism.

Interestingly, typically developing children alsoshow a significant discrepancy between their competencies in different contexts. Fischer and colleagues refer to these two very different levelsof competence as functional versus optimal levels(Fischer, Bullock, Rotenberg, & Raya, 1993).They argue that all behavior arises from collabor-ation of person and context. High-support contextsevoke optimal levels of performance, whereas low-support contexts evoke much lower, functionallevels of performance. Thus, educators who areassessing a child's abilities must think in terms of arange of behaviors and must carefully consider context as an integral part of any competence theyassess.

To understand why children with autism have anunusually large discrepancy between their funct-ional and optimal performance levels, it may beuseful to consider how typically developing child-ren eventually come to be able to perform newlyacquired behaviors in low-support environments.Fischer et al. (1993) suggest that high-support con-texts serve to activate complex neural systemsthrough short-term memory processes. At first, anewly acquired skill is fragile because it isdependent on induced short-term memory com-

ponents that are not yet subject to long-termmemory encoding. The input provided by the high-support context pushes the neural system into ahigher level state that is not available spontan-eously. The state itself cannot yet be regenerated


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alone without appropriate contextual input. Even-tually, the child encodes the learned behavior (and

perhaps aspects of the high-support environmentas well) in long-term memory. As a result, thechild becomes able to spontaneously regenerate the

behavior at a later time in the absence of immed-iate context support. We suggest that it is suchencoding and long-term memory processes that areimpaired in children with autism and that suchimpairments help to explain the large discrepancy

between their optimal and functional performancelevels. There is ample evidence that children withautism have not only attention problems butsignificant visual and auditory memory limitationsas well (Ameli, Courchesne, Lincoln, Kaufman, &Grillon, 1988; Boucher & Warrington, 1976;Klinger & Dawson, 1995; Minshew & Gold-stein,1993).

Several strategies can be used to minimizediscrepancies between optimal and functionallevels of performance in children with autism. The

programs reviewed previously typically provide ahigh-support environment for the acquisition of new behaviors and then gradually fade the highlevel of contextual support and systematically gen-eralize the newly acquired behaviors to more com-

plex, natural environments. The high-support en-vironment is achieved in a variety of ways, rangingfrom methods that stress specific periods of one-to-one teaching in a distraction-free environment(Lovaas, 1987; Rogers & DiLalla, 1991) to thosethat capitalize on brief intensive teaching opport-unities that spontaneously occur in the classroomthroughout the day (McGee et al., 1994). General-ization of skills to low-support environments alsocan be achieved in a variety of ways. Fading thelevel of prompts while gradually increasing thelevel of environmental complexity is a commonstrategy. For example, prompts may initiallyinvolve handover-hand guidance and eventuallymove to modeling of the learned behavior. Social

behaviors initially may be taught in the context of adult-child interactions and eventually involve oneor more peers. Like other programs, the TEACCH

program advocates changing only one feature of the environment at a time during the process of generalization.

Element Three: Need forPredictability and RoutineOne of the symptoms of autistic disorder is a strictadherence to specific routines and need for same-ness in the environment. This feature of thesyndrome was recognized as early as 1943 in theoriginal writings of Kanner. Although all children,especially those with developmental disabilities,thrive on routine and predictability, the child withautism seems especially sensitive to changes in theenvironment and routine. Studies have shown thatchildren with autism become more socially respon-sive and attentive when information is provided ina highly predictable manner and, conversely, thattheir behavior is severely disrupted when the samestimuli are presented in an unpredictable manner (Dawson & Lewy, 1989; Ferrara & Hill, 1980). Inthe classroom, children with autism have difficultywith transitions from one activity to another and with any unanticipated change from expectations,such as a substitute teacher or field trip. It is notyet understood why children with autism havesuch a strong need for predictability and routine. Ithas been theorized, however, that it stems, in part,from difficulties in arousal modulation (Dawson &Lewy, 1989) and from impairments in memory(Klinger & Dawson, 1995) and in processing of temporal information (Hermelin & O'Connor,1970).

The programs reviewed adopt a number of different strategies to assist the child with autismwith the inevitable changes in routine and activet-ies that a typical day involves. First, most

programs are highly structured and routine.Programs that are more child directed and com-

plex, such as the Walden Preschool Program, relyon the assistance of several teachers who systemat-ically facilitate each child's use of the environmentand transitions from one activity to another. Inother programs, visual cues, such as colored shapes, photos, and written words, often are used to label and define specific activities and activitycenters. Specific strategies for minimizing thechild's distress and confusion during transitionsfrom one activity to another are often imple-mented, including giving ample warning, walkingthe child through the transition, providing atransitional object and other visual aids, and carrying out a familiar ritual during the transition.


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In addition, visual daily schedules, in the form of pictures or written words, are used in many pro-grams.

Element Four: A FunctionalApproach to Problem BehaviorsYoung children with autism often display verychallenging behavior. The preschool curricula rev-iewed previously all address this issue. The goaladvocated by most programs is to prevent thedevelopment of problem behaviors. Most pro-grams achieve this by increasing the children'sinterest and engagement in classroom activities. Inthe Walden Program, this approach is described as"increasing fun decreases behavior problems"(McGee et al., 1994, p. 146). For example, chil-dren are provided with choices regarding in whichactivities they want to engage, and attempts aremade to include many activities that involve highly

preferred play materials or topic areas. Another strategy for engaging the child in classroom act-ivities is to provide a highly structured classroomenvironment, thereby preventing behavior prob-lems by increasing the children's understanding of the classroom routine and specific activities and by

promoting the children's independence and success(see, especially, the TEACCH program).

When problem behaviors persist, this typically ishandled by carrying out a functional assessment of the problem behavior and teaching alternativeappropriate behaviors that serve the same functionfor the child. This approach has been described indetail by Donnellan, Mirenda, Mesaros, and Fass-

bender (1984) and others. It usually involves threesteps. First, a detailed record of the behavior ismade, including the situations in which the beha-vior occurred, time of day, events that preceded the

behavior, and how others responded. Based on patterns apparent in the behavior record, hypot-heses are then generated regarding the function the

behavior serves for the child. Often this is acommunicative function ("I need help," "I don'tlike this"). For example, the child who throws toysonly during free play time may be requesting helpfrom teachers, perhaps because he or she becomesconfused during the unstructured free play period and has not learned to find and start a new activityon his or her own. The third step is to change theenvironment to support appropriate behavior and

to teach the child appropriate behaviors to copeeffectively with the situation, with particular emp-hasis on teaching the child communication skills.In the previous example, the child may be pro-vided with a board that shows two activities for thechild to choose from so that his or her choice-making skills are promoted. In addition, the child may be taught how to request help through words,

pictures, gestures, and/or manual sign. Teachersmay have the child practice the new requestingskill and then prompt the skill at appropriate timesin the classroom before they expect the child torequest help on his or her own.

Element Five: Transitionfrom the Preschool ClassroomAs discussed previously, children with autism havedifficulty making changes easily and generalizing

previously acquired skills to new environments.Given these difficulties, it is understandable thatthe transition from preschool to kindergarten or first grade is challenging for many children withautism. Most early intervention programs reviewed recognize this transition as a critical point in thechildren's education and consequently devote agreat deal of time and effort to make the transitionas successful as possible. Among the programs,there is general agreement regarding how best tofacilitate a successful transition to placements

beyond preschool. Descriptions of these methodsfollow.

It is generally agreed that one of the most impor-tant factors in preparing children for post-

preschool placements is teaching them to functionas independently as possible in the classroom. Be-cause independence skills are acquired over a

period of years, most programs begin to systemat-ically teach them as soon as a child enters the

preschool program. Powers (1992) suggested thefollowing beginning list of "survival" skills thatchildren need in order to function independently ina general classroom: Complying with adult requests Taking turns Listening to directions from afar or near Sitting quietly during activities Volunteering Raising one's hand to solicit attention Walking in line


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Using toilets in classroom versus in thehallway

Picking up toys after use Communicating about basic needs

Children who possess these skills are much more

likely to function successfully in a general edu-cation environment and to have access to a wider range of post-preschool placements. McClannahanand Krantz (1994) suggested several more advan-ced classroom skills, such as following throughwith adult instruction, sustaining engagement inwork activities, using a delayed reinforcement sys-tem, and moving from one activity to another withminimal assistance.

Most programs take an active role in assisting parents and school districts in finding a placementfor each child. Teachers help investigate the pos-sible placement options and assist in finding the

placement that is the best match for the child based on factors such as class size, degree of classroomstructure, and teaching style. Once a placement isfound, preschool staff often visit the classroom and make an inventory of the skills the child will need in order to function as independently as possible inthe new placement. These skills are then incorp-orated into the child's preschool curriculum goalsand are systematically taught, practiced, prompted,and refined. McClannahan and Krantz (1994) pro-vided several examples of such skills, which mightinclude requesting a bathroom pass, using a cubby,and saying the new teacher's name. As part of their efforts in preparing children for post-preschool

placements, the Princeton program encourages parents to engage their children in integrated settings such as religious schools, dance or gym-nastics classes, and after-school recreation prog-rams. These preliminary settings are used to eval-uate the child's ability to function in an integrated setting and to work on skills that he or she willneed in order to be successful. Most preschool

programs also assist in training the post-preschoolstaff. For instance, staff from the May program

provide an 8-day workshop to teachers and otherswho will be working with their graduating chil-dren. Finally, the transition from preschool to thenext placement is often accomplished gradually.Children 's time in the preschool classroom often issystematically decreased, whereas their time in

kindergarten or first grade is increased. In thisway, the child's performance in the new placementcan be evaluated, and skill impairments can beidentified. Then, the child can work on refining theskills needed for his or her new placement in thefamiliar and safe environment of the preschoolclassroom. In this way, the child is given thegreatest chance of achieving success in his or her

post-preschool placement.

Element Six: Family InvolvementParents' involvement in the education of their child with autism has been viewed as an important factor for success since the 1980s. On the heels of anunfortunate era in which "refrigerator parents"were seen as the cause of autism, Schopler and Reichler (1971) were among the first to advocate

parents as "co-therapists" in interventions for chil-dren with autism. In the programs first designed bySchopler, who eventually established theTEACCH program, parents were taught basictechniques of developmental therapy, participated in therapy with their child and a staff therapist, and continued therapy at home. Schopler and Reichler found that the children made significant progressand that they tended to demonstrate higher devel-opmental skills when interacting with their parentthan when interacting with the therapist. Because

parents spend so much more time with their chil-dren, it is recognized that they often can achieve agreater understanding of their child's needs and

provide unique insight into creating an intervene-tion plan. By including parents in the interventionswith children, greater maintenance and general-ization of skills also can be achieved. Also, in-cluding parents in the interventions with youngchildren with autism can increase parents' feelingsof relatedness with their child and increase their sense of competence as parents, thereby decreasingemotional stress and facilitating well-being (seeChapters 12 and 22).

In keeping with Schopler and Reichler's (1971)advocacy, all of the programs recognize that

parents are a critical component in early inter-vention with children with autism. All devote timeand resources to training parents and includingthem in the educational process. This is achieved in different ways. Some programs require signi-ficant time commitments on the part of the family


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and strongly endorse the parents' use of specific behavior strategies to increase the children's skills.Most programs, however, allow parents to choosehow they want to be involved and which skillsthey want to work on at home. There is variabilityacross programs regarding whether parent trainingis conducted at home, at school, or both. All pro-grams are sensitive to the stresses often encoun-tered by families who have a child with autism and

provide parent groups and other types of emotionalsupport.

Intensity of Interventionand Other Common ElementsWe believe it is important to emphasize that all

but one of the programs involve at least 20hours a week of school-based intervention (theLEAP program is 15 hours per week), and so-me involve a substantially greater number of hours. The range of school-based hours per week is from 15 to 40, with an average of 27hours. Although it is not possible to concludefrom these data what is the necessary and sufficient number of hours per week of school-

based intervention required for a positiveoutcome, this information does offer an est-imate of the number of school-based servicehours needed by young children with autism.Unfortunately, 27 hours is a substantially gre-ater amount of intervention than that often

provided by most public school systems duringthe preschool period. Moreover, all programsincluded a parent training component, and,therefore, the number of hours of interventionthat children are actually receiving is likelysubstantially greater than the number of school-based hours provided.

In addition to the six elements described thatare common to most programs reviewed, severalother features were often observed. These includethe use of a range of augmentative communicationmethods, occupational therapy services, and anemphasis on the development of trusting, positivesocial relationships (rather than focusing solely onthe acquisition of specific social behaviors) (e.g.,Rogers & DiLalla, 1991). Furthermore, many pro-grams advocate the use of typically developing

peers as promoters of social behavior for childrenwith autism and as positive role models in the

classroom (Strain & Cordisco, 1994). Most pro-grams emphasize the need to help the child withautism develop independence, initiative, and choice-making skills.

FUTURE DIRECTIONS

Suggestions for Improving Second-GenerationResearch on Early InterventionOne of the most promising findings in this reviewwas that all eight early intervention programsdemonstrated notable gains by children with aut-ism. Because the level of success achieved across

programs was fairly similar, conclusions regardingrecommended practices for young children withautism stem from an analysis of the programs'common features. There are, however, limitationsregarding the conclusions that can be made at this

point concerning the effectiveness of early inter-vention in autism. For example, no firm conclu-sions can be drawn yet regarding which types of interventions work best for different children (e.g.,verbal versus. nonverbal) or how much intervene-tion is needed in order to be maximally effective.Such issues might have been addressed using thestatistical technique of meta-analysis if invest-igators had utilized similar methods for char-acterizing individual differences in children (e.g.,standardized IQ scores) and for quantifying pro-gress.

To facilitate future analyses of the effectivenessof early intervention in autism, investigators sho-uld consider standardizing measures of cognitive,language, social, and adaptive abilities and measures of rates of developmental change across

programs. This would allow for a direct compare-ison across different programs and provide infor-mation regarding the effectiveness of a specifictype of intervention for children with differentlevels of ability. In addition, investigators rarely

provided adequate information regarding the typeand amount of support services that childrenreceived when they graduated to general educationenvironments. This made it difficult to evaluatewhat was meant when it was reported that the child was successfully included in a general educationclassroom. Thus, it is also recommended that in-vestigators consider standardizing the way that

post-preschool placements and support services are


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characterized. Finally, in an era when federal and state funding of early intervention is in jeopardy,including a careful costbenefit analysis would beuseful (see Lovaas, 1987).

Intervention Methodsfor Infants with AutismAs the ability to identify infants with autismimproves, so will the need to develop methods for intervening with young infants with autism and their parents. Although it is likely that such inter-ventions will incorporate most, if not all, of theelements described previously, they will also havefeatures that are specifically tailored to the needsof a young infant and his or her parents.

This section briefly describes the early interven-tion research conducted by Dawson and her collea-gues. Elsewhere, Dawson and her co-workers(Dawson & Galpert, 1990; Dawson & Lewy, 1989;Klinger & Dawson, 1992) have discussed in depthone approach to very early intervention with youngchildren with autism. Because these strategies are

based on typical patterns of parent-infant inter-action, they are particularly well suited for usewith infants with autism and their parents. Dawson(1991; Dawson & Lewy, 1989) has suggested that,like typically developing infants, young childrenwith autism have a narrow range of optimal stim-ulation. Their ability to make sense of and relate totheir environments depends in large part on theamount of regularity and familiarity provided.Based on these assumptions, Dawson developed aseries of intervention strategies designed to allowchildren with autism to maximize optimal levels of stimulation and to increase their attention to and comprehension of social information.

The first strategy involves closely following thechild's lead, usually by imitating the child's beh-avior. Imitation of an infant's behavior is one of the most common forms of communication bet-ween a parent and infant during the first year of life. Parental imitation serves several social func-tions, including increasing infant attentiveness tosocial interaction (Piaget, 1962), promoting turn-taking behavior (Stern, 1985), facilitating a senseof self as related to others (Uzgiris, 1981), enhan-cing imitation of others, and shaping emotionalexpression and empathy (Malatesta & Haviland,1982; Meltzoff & Gopnik, 1993). Imitating an

infant also allows the infant to control the amountof stimulation experienced by placing the infant inthe role of initiator (Field, 1977, 1979). Studieshave shown that children with autism exhibit inc-reased amounts of social attention and respon-siveness when they are imitated (Dawson &Adams, 1984; Dawson & Galpert, 1990; Tieger-man & Primavera, 1981, 1984).

Imitation by parents has been a component of other early intervention programs as well.Mahoney and Powell (1988) developed a parenting

program for children with developmental disabilities from birth to 3 years old (TransactionalIntervention Program). The goal of the programwas to increase parental use of turn-taking skills byimitating the child's behavior and following thechild's lead. Children of parents who were high inimplementation of the program made greater deve-lopmental gains than children of parents who werelow in implementation. These gains were mediated

by affective characteristics of the parents, withchildren of high-affect parents displaying thegreatest gains.

Elaborating on the basic technique of imitation,Klinger and Dawson (1992) developed a series of social interactive strategies designed to promoteearly social skills in young children with autism,including contingency, social gaze, turn taking,imitation, shared attention, and communicative in-tent. These strategies are based on the followingfive principles:1. They are modeled from naturally occurring

patterns of early social interaction. As in typ-ical development, social skills are facilitated through play rather than explicitly taught.

2. They are based on knowledge of typical devel-opmental sequences, progressing from verysimple interactions to increasingly complex so-cial interactive skills.

3. They incorporate the principle of scaffolding,whereby parents provide stimulation that isclose to or slightly above the child's currentdevelopmental level (Bruner, 1982). This isdone by creating an augmented scaffold inwhich social experiences are not only geared toward the child's developmental level but alsoare exaggerated and simplified so that the rele-vant aspects of social interaction are distilled,

become highly salient, and are more easily


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comprehended.4. They are designed to be sensitive to the child's

narrow range of optimal stimulation.5. They place the child in the role of initiator,

thus allowing the child to regulate the amountof stimulation received and to avoid a passiverole in the interaction.

Based on case studies using these methods(Klinger & Dawson, 1992), it can be concluded that the developmental goals of young childrenwith autism are similar to those of typically devel-oping infants. These include, among others, thedevelopment of strategies for self-regulation of arousal; the establishment of a trusting, loving rel-ationship between the infant and his or her primarycaregivers that incorporates shared affect and shared attention; the promotion of social play viaritualized games; and the acquisition of commun-icative intent. Among the programs reviewed for this chapter, that developed by Rogers and her colleagues (Rogers & DiLalla, 1991; Rogers &Lewis, 1989; Rogers et al., 1986) comes closest tosharing these early goals, especially in terms of itsemphasis on the development of positive rela-tionships with adults and the use of positive affectto increase the child's social attention and moti-vation.

The Gap Between What IsKnown and What Is ImplementedAs investigators continue to refine methods and develop new ones for helping young children withautism and as research studies further investigatethe effectiveness of early intervention in autism it

becomes all too apparent that there is a serious gap between the state of our knowledge of early inter-vention methods for children with autism and themethods actually used in most public schoolsystems. Despite careful costbenefit analyses(Lovaas, 1987), legislators and voting citizensunfortunately often fail to support the level of fun-ding needed to implement the programs described in this chapter. For example, it is not uncommonfor a preschool-age child with autism to receiveless than 27 hours of classroom intervention.Moreover, the staff and training required to imp-lement the programs described in this chapter oftenare lacking.

If we were to implement what we now knowhow to do and to cease all efforts at the develop-ment of new methods, it is very likely that approx-imately half of all children with autism would beable to function in a general education program bythe time they reached elementary school age. If intervention methods were initiated at even earlier ages, which should be possible given the earlydetection methods being developed, the outcomefor children with autism by 5 years of age would

probably be even more promising. Furthermore,our predictions for long-term prognosis in autismand for the need for adult services would likely besubstantially revised. Perhaps, then, one of themost important goals of investigators in this field is to become more effective communicators of our knowledge to the general public in order to garner their support. In the meantime, it is clear thatsignificant progress has been made in developingmethods of early intervention for children withautism and that our efforts at changing the courseof the lives of individuals with autism throughearly intervention have been very worthwhile.

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