Presented at ISEC 2000

Outcomes of Three Educational Interventions for British School Children with Classical Autism: A Comparative Study

Helen Richardson - University of Manchester, UK

Contributions from: Tracey Langley

Abstract

Autism is a neuro-lmmuno-developmental disorder, with an estimated UK prevalence of over 300,000. Places in specialist schools/units are very limited, and most children with autism attend moderate/severe learning difficulties (M/SLD) or mainstream schools.

The aim of this study was to compare outcomes of two specialist educational programmes for children with classical autism, namely TEACCH and Daily Life Therapy, and a SLD programme.

Parents (and teachers) completed a questionnaire to indicate "how often" their (each) child showed a behaviour/skill, using a four-point scale ('never', 'sometimes', 'very often', 'always'). 'Pre-school' and 'now' scores for 80 children were compared by statistical analyses. More life skills essential for self-esteem and social interaction, such as improved eating, drinking, sleeping, toilet training, and reduced self-injurious behaviour and physical aggression towards others, developed significantly with Daily Life Therapy than with TEACCH, which in turn was more effective than the SLD Programme. The greater efficacy of Daily Life Therapy in terms of how it may impact on brain function and immune mechanisms will be discussed.

The findings are important, because they provide a framework for adopting appropriate educational Interventions, which can optimise quality of life for all these children, reduce the impact of autism on their families, and help meet the UN commitment to appropriate education for all.

Introduction

This paper takes up the Congress theme of 'Including the excluded' from the perspective of outcomes of educational provision for children with autism spectrum disorder (ASD), in terms of the prospect for their inclusion within society as independent adults. Helping each child to improve his/her self-care and social interaction are essential pre-requisites to independent living in the community, and it is therefore imperative that educational provision addresses these needs.

The paper is in three parts: it starts with a brief review of the scale of the problem in the UK, (the number of people affected and amount of specialist provision); the main part reports data from a comparative study of progress made by British children through three educational programmes in the school setting, and the final part reviews some of the current thinking of the neurobiological basis of autism, and explores why some types of provision may be more effective than others.

The Scale of the Problem

Epidemiological studies have indicated approximately 22 per 10,000 people have ASD and IQ below 70, and at least 70 per 10,000 have ASD and IQ of 70 or above (Wing, 1996). Based on 1991 UK census figures of approximately 58 million population, of whom 13 million are children under 18 years old (NAS, UK, 1995a), leads to an estimated UK prevalence of ASD exceeding 500,000, of whom about 120,000 are children. Places in specialist schools/units for children with autism are very limited (approximately 3500), and most attend moderate/severe learning disabilities (M/SLD) or mainstream schools (NAS, UK 1995b).

Books by autists and carers highlight their concerns and frustrations regarding lack of appropriate educational provision. Carers feel that it is important for professionals to recognise the significant role of parents and other family members, and want 'voice and choice' regarding educational provision for their children with autism. They feel that children with ASD need early intervention, a structured and supportive programme, and practices which recognise the needs of the 'whole' child and which prepare him/her for active involvement in typical school and home settings.

The comparative study

Aim: The aim of the study was to compare, for children with classic autism, outcomes of a range of educational provision in a school setting. Outcomes were judged according to children's progress in a range of behaviours and skills, through two specialist educational programmes, namely TEACCH and Daily Life Therapy (DLT), and a SLD programme. We wanted to evaluate whether progress was equivalent across this range of educational provision (reported in brief by Richardson & Langley, 1997.)

Method: Seven schools took part in the study. They were selected from a list provided by the National Autistic Society (NAS), UK. Six schools were in the UK north west region, and one was in Boston, USA. Data were collated for 80 children, who had a diagnosis of classic autism, were between 3 and 18 years old, and for whom a questionnaire was completed by a parent on the child's behalf. All children could hear and see, but many were non-verbal or could vocalise only a few words or parts of words.

Parents completed a questionnaire to indicate, by box ticking, 'how often' their child showed a behaviour/skill using a four-point scale ('never', 'sometimes', 'very often', 'always'), at 'just pre-school' and 'present age'. The questionnaire asked about 70 behaviours/ skills, grouped in six categories: repetitive body movements (stereotyped sensorimotor activity), posture and gait, relationship with objects/toys, communication and relationships, cognitive/ understanding, general (which included self-care ). Teachers completed the questionnaire independently, and were asked to score the children's behaviours and skills at the 'present age' only.

The children's identities were unknown to the researchers. Coded data were used and schools kept a key to participants' identities.

'Pre-school' and 'present age/now' scores for each of 28 behaviours/skills were compared by statistical analyses (Wilcoxon matched-pairs signed ranks test).

Table 1: The main educational methods & approaches used at the schools

Each headteacher was asked which were the main educational methods used at that school.

Results: Table 1 shows the main educational methods used at each school. It can be seen that schools using TEACCH used additionally a variety of other methods. The table also shows the number of participants for each school and their age range. There was no significant difference between ages of the children attending the different schools (ANOVA, p >0.05).

Figure 1 shows improvement of eye contact for all children in the sample. This shows that whereas 33 children pre-school were rated as 'never' showing eye contact, only 3 were so rated at the present age (left hand columns). By contrast, the higher incidence rating of 'very often' showing eye contact applied to 4 children pre-school but to 45 children now; and 'always' to 2 at pre-school age but to 19 now. 'No reply' data indicate the number of respondents who left that question blank. In this and subsequent charts, improvement is indicated where the 'pre-school' columns are higher than 'present age' columns at left, but smaller than 'present age' columns at right.

For eye contact for all the children together, there was a highly significant difference between 'pre-school' and 'present age' scores, p< .0001 (Wilcoxon test, 2 tailed).

Taking all the children in the study as one sample, there was progress in most behaviours/ skills analysed. However, whilst some behaviours improved among children at all schools, other behaviours improved at only one or a few schools. Figures 2 and 3 and Table 2, ( next pages) show that 'physical aggression towards' others and 'eating problems' both improved in School D but not at other schools.

Data are summarised in Table 2, in which left hand columns show improvement for children at all schools together (significant if P [ 0.05), and columns A - G for children at individual schools, where 4indicates at least significant improvement (P [ 0.05) and B indicates borderline improvement (P >0.05<0.07), (Wilcoxon test, 2 tailed).

Table 2 : Progress in behaviours and skills for all children in the study and at the individual schools (based on Wilcoxon test, 2 tailed)

Significant progress was evident for more skills in School D than at any other school. This was especially so for life skills essential for self-care, such as improved eating, drinking, sleeping, toilet training and reduced self-harm, and for social interaction such as reduced physical aggression towards others. Comparing educational methodologies used at the schools (Table 1), the data showed that more life skills developed significantly with Daily Life Therapy than with TEACCH, which in turn was more effective than the SLD Programme.

Further analyses indicated that the differences in improvement at the different schools could not be explained either by differences in pre-school age scores of the features analysed between children at the different schools, or by parents over - or under- evaluating their children's behavioural development at the present age.

Neurobiological basis of autism, and why some educational programmes may be more effective than others

Current evidence implicates impairment of neurobiological, endocrine, immune and gastrointestinal systems in the aetiology of autism, including systems using 'common' chemical modulators serotonin, secretin and corticotrohpin releasing hormone (CRH), for which abnormal levels have been reported in autism (Warren & Singh, 1996, Tordjman et al., 1997).

Due to interdependence of, and interaction between, these various systems, it can be anticipated that impaired function in any one part may impact and intensify dysfunction of the others. For example, dysfunction of the immune system impacts on the arousal and endocrine regulatory systems within the brainstem, resulting in disruption of sleep patterns, hyperactivity, anxiety and altered eating behaviour (Sternberg and Gold, 1997).

Daily Life Therapy aims to regularise body rhythms, such as sleeping and eating behaviour, regulated by the hypothalamus. The efficacy of Daily Life Therapy may result partly from this focus on improving daily rhythms and may achieve this by influencing hypothalamic function. Hypothalamic function normally facilitates the interdependent functions of the immune, endocrine and gastrointestinal systems, which are compromised in autism. Just as dysfunction in one system leads to imbalance in the others, improved function in one system leads to improved function in other interdependent systems.

Additionally, vigorous physical exercise (PE) which is a key feature in Daily Life Therapy, may help to reduce anxiety by release of endorphins, in turn reducing aggression, hyperactivity, and self-stimulatory behaviour including self-harm, as well as improving movement co-ordination. As a result, children start to learn to manage their own behaviour 'from within themselves' rather than merely being passive recipients of externally applied behaviour modification, and this builds trust and self-esteem. Group dynamics-based PE aims to improve co-operation and activities with other children as a bridge to social development. Thus the holistic approach of Daily Life Therapy works on the neurobiological basis of autism, not just its symptoms. It achieves its outcomes without use of either medication or physical/mechanical restraint.

Future directions

Future research would ideally follow progress of these children since the time of the study (1995/96). It could also extend this study to include additional schools, or to follow longitudinal development of cohorts of children, and more in-depth evaluation of progress in cognitive skills through the various programmes.

Concluding remarks: why these findings are important: The findings have important implications for 'best value' provision for three main reasons:

• They provide a framework for adopting appropriate educational interventions, which can optimise quality of life for the children, and reduce the impact of autism on their families.
• Reduction in physical aggression is a major determinant in decisions regarding need for long term (adult) residential care, with all the social and cost implications which that entails. Students who completed the DLT Programme last year are in gainful employment, (e.g. computing, bakery, mail sorting) or enrolled in Community College. None is in residential care.
• 'Daily Life Therapy' day programme for 2000/2001 will cost $33,407 for the '44 weeks educational year'. This is lower than the cost of all other programmes, which are less effective and generally have fewer weeks. (Inevitably, UK children must attend the residential programme, which in 2000/1will cost $94,290, but DLT continues at the residence, providing added value through a '24 hours' programme).

Practitioners and parents recognise that, to develop full potential, each child needs an educational programme appropriate to his/her individual needs and that the diversity of ASD means that no one approach is equally effective for all children. Outcomes such as those indicated by the comparative study show it would make sense to support the aspirations of parents by making Daily Life Therapy available within the UK as a programme of choice for the benefit of many children with classic autism.

Conference Discussion:

Discussion centred around main themes of

1. the extent to which outcomes of Daily Life Therapy are generalised and maintained after students leave the school; current reporting from the school is that all children who completed the programme last year have maintained progress and are in gainful employment or further educational settings. However, children whose attendance at the school ends before completion of the programme may not maintain progress, as would be expected with any therapy that is halted part way through.
2. whether the apparently greater progress with Daily Life Therapy can be explained by the extent to which parents' ratings of their child's progress are likely to be influenced by the amount they have had to fight for, and pay for, that educational programme, and the consequent greater aspirations of parents with children at the school; apart from the facts that parents normally act in their child's best interests, and that it is appropriate to assume parental objectivity and integrity in this area, two strands of evidence suggest that this is not the explanation: 1) the children's current behavioural development evaluated by parents generally matched that of the teachers; 2) recent reports by independent UK psychologists of individual children observed in the school setting support parental evaluations.
3. the extent to which schools report using TEACCH as a main methodology actually do so; headteachers provided information booklets and answered 'open-ended' questions about methodology. Each school using TEACCH used an additional range of methodologies, the proportion of time that each approach is used was not asked, and would be likely to vary according to the needs of individual children. The SLD school used methodologies not specifically designed for children with autism, e.g. Waldon technique and Montessori technique, the theory of which can apply to all children but is especially relevant to children with learning disabilities.
4. the extent to which children's progress in schools which use a range of methodology can be attributed to any one of those interventions, or indeed time outside the school setting: the study was unable to control for those confounding variables, but some indirect indicators may be put forward; for the schools using a range of approach, TEACCH was the common factor in the schools using TEACCH that was missing from the SLD school, suggesting that TEACCH was instrumental in the greater progress at those schools. Differing progress at the different schools using TEACCH may reflect varying emphases on TEACCH versus other methods. Stated aims of parents in sending their child with autism to school always include 'improved behaviour, self-care, social interaction' etc, suggesting that parents feel the home setting is less able than the school setting in achieving progress in these areas. The school using a single holistic 'whole day' approach designed for autism, Daily Life Therapy, was associated with greater progress than any other, suggesting that exposure to a single effective intervention can be more successful than an eclectic approach. Its greater efficacy may also result partly from intervention at school continuing at the school residence, again suggesting that a programme by trained staff was more effective than school plus the home setting in improving behaviour and progress in self care skills.

References

Boston Higashi School. (1999). Daily Life Therapy Guidelines. Boston Higashi School.

Kitahara, K. (1983). Daily Life Therapy (Vol. 1). Tokyo: Musashino Higashi Gakuen School.

National Autistic Society. (1995a). How many people are autistic? Statistics sheet 1.

The National Autistic Society, UK. National Autistic Society. (1995b). Specialist places for people with autism. Statistics sheet 2. The National Autistic Society, UK.

Richardson, H. C., Langley, T. A. (1997). The potential benefits of Daily Life Therapy for children with autism. Autism 1, 236 - 237.

Schopler, E. (1994) A statewide program for the Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH). Psychoses and Pervasive Developmental Disorders, 33, 91 - 103.

Sternberg, EM, Gold, PW (1997) The mind-body interaction in disease. Scientific American. Special Issue: Mysteries of the mind. January, 1997, 8 - 15.

Tordjman, S., Anderson, G.M., McBride, P. A., Hertzig, M. E., Snow, M. E., Hall, L. M., Thompson, S. E. & Ferrari, P. (1997). Plasma ß-endorphin, adrenocorticotropin hormone, and cortisol in autism. J. Child Psychol. Psychiat., 38, 705 - 715.

Warren, RP, Singh, VK (1996) Elevated serotonin levels in autism: association with the major histocompatibility complex. Neuropsychobiol. 34, 72 -75

Wing, L. (1996). Autistic Spectrum Disorders. No evidence for or against an increase in prevalence. BMJ 312, 327 - 8.

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