INTRODUCTION
The definition of autistic syndrome, originally described by Leo Kanner in 1943, has been refined and modified in the light of new research findings (Rutter, 1978; Schopler, 1983). Significant criteria include impairments in social relatedness, in communication, and restricted and repetitive interests and behaviors (DSM III, APA, 1980; Rutter and Schopler, 1987). The new interpretation of autistic disorder deal with the acknowledgment of its biological basis and makes parents victims of the disorders rather than its cause (Schopler, 1987). DSM III-R and DSM IV provide highly specific behavioral descriptors that have a developmental orientation and are intended to cover the entire age and intelligence spectrum (APA 1987,1994).
Viewing the autistic child as developmentally disabled with specific handicaps in different areas of functioning provide a framework for individualized long term education (Marcus, 1978; Schopler, 1 989).
The focus of intervention strategies has been changed from classical diagnostic and intervention procedures to a more functional approach, so that intervention could become more individualized and more appropriate for the child (Schopler, Reichier, Lansing, 1980).
The potential problems of ambiguity, developmental variation and vagueness in the diagnostic process become less relevant if the specific learning patterns and behavioral characteristics are clearly identified (Marcus and Stone, 1993). Because of the developmental orientation of the diagnostic criteria for autistic syndrome, the appropriate and individualized instructions are stressed as the basis for special education and treatment intervention. A comprehensive assessment is considered an essenfial first step in development and planning of an effective treatment and education program (Marcus and Stone, 1993).
The TEACCH program (Treatment and Education of Autistic and Communication Handicapped Children) is described as a comprehensive and primarily educational program, which includes diagnostic evaluation, individualized treatment, and special education for autistic and communication handicapped children (Schopler, 1986). The developmental approach of TEACCH recognizes differences between children and also differences within any particular child in the rate and nature of development across different skill areas (Lord, Bristol, Schopler, 1993). This approach emphasizes the child's capacities more than their specific deficits (Schopler, Mesibov, Hearsey, 1995).
The guiding principies and concepts of the TEACCH system are: improvement of the child's adaptation by modifying the environment to accommodate their deficits, parental collaboration with professionals, developmental diagnostic evaluation for individualized treatment and educational programs, structured teaching, skills enhancement, and the use of cognitive and behavior theory for special education and research (Schopler, 1994; Schopler, Mesibov, Hearsey, 1995). The importance of structured teaching is stressed by many researchers for the development of appropriate special education classrooms because, as Schopler demonstrated, autistic children learn better in a structured rather than in an unstructured learning situation (Schopler, Brehm et al. 1971). Structured teaching emphasizes the visual components of learning, because visual processing minimizes the deficits in auditory processing (Schopler, Mesibov, Hearsey, 1995) and the inadequate integration of cognitive and sensory stimulation processes (Cox and Schopler, 1993).
In fact, by accommodating the learning environment to the specific deficits associated with autistic syndrome, independent functioning of each student is encouraged and the student's frustrations and communication barriers, often associated with behavior problems, are avoided. To understand this relationship the "iceberg" conceptualizadon is used: above the water line are the aggressive behaviors, beneath the water line are the deficits that may cause a person with autism to act aggressively. For this reason the TEACCH program strategies for an educational program include special techniques of teaching and environmental changes that are based on structured education principles (Cox and Schopler, 1993). It is necessary to emphasize positive strategies, increase spontaneous communication even in children with severe language deficits, and to use structures adapted to different ages, developmental levels and individual needs to minimize difficulties before behavior problems occur (Lord, Bristol, Schopler, 1993).
For years, the Oasi Institute has been treating children and adolescents with autism and has recently begun a specific formation course based on the TEACCH program. Those efforts are guided and supervised by Theo Peeters from Opleindingscentrum Autism-Belgium.
In this study we want to verify the TEACCH model hypothesis.
Specifically, we want to test whether special education, as described
in the TEACCH program, for autistic children increases learning
capacities and spontaneous communication, and reduces behavioral
problems.
Method
Subjects
The group is composed of 18 autistic children with chronological age from 7 to 18 years (mean age = 13.92 years), 17 boys and 1 girl. The diagnosis of autism was made using the criteria of DSM-IV (American Psychiatric Association, 1994) and the CARS scale, considering a cut off of 30 for children before age 13, and a cut off of 27 for adolescents 13 or over, as is suggested by Mesibov and Schopler (Schopler et al., 1988; Mesibov et al., 1989).
The children's intellectual level ranged from severe retardation
to profound. The mental age (calculated from PEP-R and VABS)
ranges from 3 to 26 months (mean age = 16 months).
Procedure
The period of treatment was 18 months. Before the treatment we
assesed all the children for a baseline measurement (pre-test).
The evaluations were repeated after 12 months (post-test 1) and
after 18 months of treatment (post-test 2). We compared the results
obtained from pre-test and post-test 1 (I-II), pre-test and post-test
2 and post-test 1 and post-test2 (II-III). The first application
of EFC (published in January 95) was made six months after the
beginning of treatment, and then every four months and after one
year of treatment.
The instruments we used for assessment are suggested by many researchers
(Perry & Factor, 1989; Rodrigue, Morgan & Geffken, 1991;
Schopler, Reichler, Bashford, Lansing and Marcus, 1990; Bathelemy
C., Homerey L., Lelord G., 1995) for autistic children's assessment.
1. The VABS (Vineland Adaptive Behavior Scale - Survey Form), is an extensive
revision of the Vineland Social Maturity Scale (Doll, 1965), and
assesses adaptive behavior using five possible domains: communication,
daily living skills, socialization, motor skills, and maladaptive
behavior. It has been used extensively with children with mental
retardation and has been shown to have utility in the assessment
of children with autism and Down syndrome (Perry, & Factor,
1989; Rodrigue, Morgan, & Geffken, 1991).
2. The Psychoeducational Profile Revised (PEP-R) offers
a developmental approach to the assessment of children with autism
or related developmental disorders. It is also an inventory of
behaviors and skills designed to identify uneven and idiosyncratic
learning patterns. Used as an assessment, the PEP-R provides
information on developmental functioning in imitation, perception,
fine motor, gross motor, eye-hand integration, cognitive performance,
and cognitive verbal areas. The PEP-R is designed primariliy
for planning individualized curricula.
3. The EFC, Echelle d'évaluation Fonctionnelle des Comportements,
is a behavioral scale that evatuate 13 neuropsychological
functions: attention, perception, association, intention, tone,
motor activity, imitation, emotion, instinct, contact, communication,
regulation, cognition. For each function there are 8 items scored
on a scale from 0 (absent behavior) to 4 (permanent behavior).
When used for a longitudinal assessment the EFC permits the observation
of changes in psychophysiological functioning of all the assessed
areas. In spite of is lack of statistical validation, the EFC
has good clinical validity (Barthelemy C., Homery L., Leford G.,
1995).
4. Structured observations of disadaptive behavior were made according
to Soresi's indications (1978). We have observed behavioral problems
in twelve periods of 15 minutes each, before the beginning of
treatment (pre-test), after 12 months (post-test 1) and after
18 months (post-test 2). Motor stereotypes, stereotypic, self-injurious
and aggressive behaviors were the behavioral problems observed.
5. Structured observation of spontaneous communication were made,
according to Watson's suggestions (1989), before the beginning
of intervention and after 18 months of treatment. Each child
was observed for 4 hours during different daily activities. The
considered dimensions of communication were: function (purpose
of communication), context and mode.
Treatment
The applied treatment intervention is based on three fundamental principles: individual educational program, environmental adaptation, and alternative communication training.
The individual educational intervention programs (IEP) were planned and structured for each child using the data collected from VABS, PEP- R and from structured observations of children's abilities. The objectives target were on personal independence, community abilities, functional communication, motor skills, eye-hand coordination, cognitive performances and leisure time.
For the environmental adaptation we have followed the four major components of structured teaching according to TEACCH model: Physical organization, schedules, work systems, and tasks organization (Schopler, 1994; Schopler, Mesibov, Hearsey, 1995). For physical organization, we used different rooms for each activity. There were visually clear areas and boundaries for specific activities to help students to understand and function effectively in their environments and to focus their attention on the most relevant aspects of their tasks. We organized places for independent work, learning sessions, community activities, motor skill activity, organized leisure time, and free leisure time.
Schedules were used to explain which activities would occur and in what sequence. They also help children to anticipase and to predict activity. Each child had an object or a transition card to change or to move from one activity or one place to another. The entire work-day schedules were organized in a simple and clear way and were accommodated to the children's developmental level (using objects, objects on cards, and photos).
Work sessions were organized with different visual work systems for different children (i.e. left to right, with numbers, with letters, with colors, etc.). The work system informs each student of what is expected of them in their independent work areas and helps them work independently of teacher supension.
Work sessions were: independent activities (during these sessions the children work independently in simple activities), learning sessions (the children learn simple activities with a teacher), motor activities, daily living activities (community, domestic and personal), and leisure time.
The last component of structured teaching is task organization: the organization of materials used in the different work systems provides visually clear guidelines to understand and complete the task without direct adult supervision.
All of these components were individualized for each child according to the developmental level and the individual needs.
Alternative communication was organized to promote comprehension
and request, using objects, cards, photos and pictures. Children
at the higher level of comprehension used picture books for the
same purposes. The main purpose was to maximize communication
at the child's developmental level.
RESULTS
The results obtained are summarized on tables 1-5.
Table 1 shows the differences between the three applications of
Vineland Scale on pre-test, post-test 1 and post-test 2, analyzed
with Wilcoxon test. We found statistical significance (p<
.01, .05) of the differences between pre-test and post-test 1
(I-II) and between pre-test and post-test 2 (I-III) in communication,
daily living skills and socialization domains. The diferences
between post-test 1 and post-test 2 (II-III) showed statistical
significance (p< .01, .02) only in daily living skills (domestic
and community) and play and leisure but didn't show any statistical
significance in communication, personal domains, socialization
and interpersonal relationships.
Table 2 shows the differences between the three application of
PEP-R analyzed with Wilcoxon test. In the "Passing"
categories, we found statistical significance of the differences
between pre-test and post-test 1 (I-II) (p< .01, .02, .05)
and pre-test and post-test 2 (I-III) (p< .01) in imitation,
fine motor, gross motor, eye-hand integration, cognitive performances.
The differences between post-test 1 and post-test 2 (II-III)
showed statistical significance (p< .05, .01) in imitation,
gross motor, cognitive performances. Statistical significance
was also found in the "Emerging" categories compared
in pre-test and post-test 1 in cognitive performances.
Table 3 shows the number of children in progress between the first
and the last (after 12 months of treatment) application of EFC
analyzed with X2. We considered only the areas and items where
improvements in 1/3 of subjects were found. We found improvements
in the attention area in items 1, 2, 8 (p<.05 in item 2); in
association area in items 1, 8; in emotion area in item 1; in
communication area in items 1, 3 (p< .05 in item l); in instinct
area in items 3, 4; in regulation area in items 1, 4 (p< .05
in item 4). On the whole, we found a small change in children's
scores with a percentage from 50% to 78%.
Table 4 shows the amount of behavioral problems reduced after
18 months of treatment. The behavioral problems were grouped
in four categories: stereotyped behaviors, stereotyped movements,
self-injurious behaviors, aggressiveness. We analyzed the data
using X2 test. We found statistical significance in the reduction
of self-injurious and stereotyped behaviors (p< .05), and of
stereotyped movements (p< .01). We didn't find any statistical
significance in the reduction of aggressive behaviors, probably
because of the small sample (2 behaviors observed).
In table 5 we analyze the functions and the modes of communication
using X2 test. We compared the results obtained from the observations
made before and after 18 months of treatment. We observed an
increase in frequency of communications made by the children.
We found statistical significance in all the functions of communication
(p<.01, .05), except in "asking something". The
amount and the frequencies of communication's mode used by the
children is increased (p<.01). We found statisticalty significant
improvements in communication with motor/gesture and objects (p<.01),
and in pre-verbal mode (p<.05). There was an increase in verbal
communication without statistical significance. Moreover, we
observed two new modes of communication (objects on card, photos/pictures).
DISCUSSION
It is generally known that is difficult to evaluate the results of a treatment. There are a lot of nonspecific factors involved with treatment outcomes (Schopler, 1987). The evaluation of treatment is difficult to measure and it is further difficult to distinguish between short-term and long-term effects (Schopler, Mesibov, Baker, 1982).
If we consider the developmental level of our children (severe and profound mental retardation) and their chronological age, we judge satisfactory the results obtained after 18 months of treatment with the application of TEACCH program principles. We used structured and continuos intervention, environmental adaptation and specific training for professionals involved in the treatment.
On the whole, we found an improvement of children's competences (Tab. 1, 2, 3), a reduction of behavioral problems (Tab. 4) and an increase of spontaneous communication (Tab. 5).
VABS and PEP-R results show more progresses between pre-test and post-test 2, whereas there are statistically significant progress only in some areas between post-test 1 and post-test 2. Probably, this depends on our children's slowness in learning because of severe and profound mental retardation. In detail, the comparison between the first and the third evaluation after 18 months of treatment (pre-test 1 post-test2) shows a higher statistical significance (p< .01) in all domains, except in perception domain, The comparison between the second and the third application after 6 months (post-test 1 post-test 2) shows statistical significance in three VABS domains (community p< .05, domestic p< .01, play and leisure p< .01) and in three PEP-R domains (cognitive performances p<.05, imitation p<.05, gross motor p< .01).
Analyzing VABS results we didn't find any statistical significance in communication and in interpersonal relationship domains, probably because they are connected with the characteristics of autistic disorder (isolation, lack of interest in other people, difficulty in comprehension of language .... )
PEP-R results regarding perception and cognitive performances could be explained in a different way. With regard to perception, auditory perception items (n.35: hears and orients to sound clapper, n.57: hears and orients to sound of whistle, n.111: hears and orients to sound of handbell) deal with the attention's level during the evaluation. The great variability of the answers to these items in each evaluation may be due to the weak attention of the children composing our group. In the same way, the responses obtained on some visual perception items can be explained (n.3: visually tracks movements, n.4: visual pursuit across midline). In two items regarding perception (n.7: displays eye dominance, n.32: matches colored blocks with disks) respectively 83% and 61% of our children didn't obtain the "passing" category, probably because of the severe mental retardation. Regarding cognitive performances, our children obtain the "passing" categories only in items whose mental age level range from 10 to 36 months (i.e. 34% of items).
The analysis of EFC resufts showed improvements only in few items of attention's, association's, emotion's, communication's, instinct's and regulation's areas. These items are, probably, more sensitive to the treatment. The small changes in children's score could be connected to the items that describe the 13 functions. These items refer to typical characteristics of autistic disorder and, then, they are hard to change in a short period of time. Even if the scale has good clinical validity describing functional behaviors, it isn't sensitive enough to evaluate the effects of treatment. We must, also, remember that this scale hasn't yet a statistical validity. Our interest was focused on behavioral problems. The management of these behaviors is difficult in severe mentally retarded and autistic children. When these behaviors are very intense and frequent learning and emission of adaptive behaviors may be strongly affected.
The positive data obtained, expressed through directed observation of behaviors, demonstrate the positive influence of this intervention in the management of behavioral problems. In fact, there is a reduction of all these behaviors with a statistical significance of motor and verbal stereotypes (p<.01). Moreover, we noticed that in most cases behavioral problerns increased during non organized leisure time, and decreased in all the structured activities.
The results of the observations of spontaneous communication show an increase of frequencies in function and mode. The frequencies in modes are greater than frequencies in functions because the children often use two different modes (verbal and gesture) for the same communication. All the functions examined become greater in number. The function "asking something" hasn't any statistical significance, probably because our children asks spontaneously only for basic needs. All the modes examined became greater in numbers, also. The verbal mode hasn't any statistical significance because of the small group of children (4) that speak adequately. The new modes observed (objects on cards and photos or pictures) deal with the intervention's strategies.
Our environment adaptation according to specific children's needs and intervention based on a structured learning, using visual tasks, give us promising results in future work with autistic children.
This study data confirm the efficacy of applied TEACCH intervention
in our group of Italian autistic children. To be sure that these
data deal with TEACCH strategies, we think it is important to
introduce a control group. This group will be made by autistic
children matched to the experimental group except for the kind
of treatment. The results obtained from these two differently
treated group will be compared to demonstrate the TEACCH method
effectiveness.
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Table 1.Statistical significance of the differences between the three application of VABS:
pre-test / post-test 1 (I-II),
pre-test 1/ post-test2 (I-III), post-test 1/ post-test2 (II-III).
| VABS | I-II
Wilcoxon p< | I-III
Wilcoxon p< | II-III
Wilcoxon p< |
| COMMUNICATION
Receptive Expressive | .01
.01 ns | .01
.01 .05 | ns
ns ns |
| DAILY LIVING SKILLS
Personal Domestic Community | .01
.01 .05 .01 | .01
.01 .01 .01 | .02
ns .01 .02 |
| SOCIALIZATION
Interpersonal relationships Play and leisure | .01
.02 .01 | .01
.02 .01 | ns
ns .01 |
Table 2.Statistical significance af the differences between the three application of PEP-R:
pre-test / post-test 1 (I-II),
pre-test / post-test2 (I-III), post-test 1/ post-test 2 (II-III).
| PEP-R | I-II
Wilcoxon p< | I-III
Wilcoxon p< | II-III
Wilcoxon p< | |
| IMITATION | ||||
| PERCEPTION | ||||
| FINE MOTOR | ||||
| GROSS MOTOR | ||||
| EYE-HAND | ||||
| INTEGRATION | ||||
| COGNITIVE | ||||
| PERFORMANCE | ||||
| TOTAL | ||||
Table 3. Number of children in
progress in the EFC results, after 12 months of treatment
| EFC |
|
|
| ATTENTION | ||
| Item 1 | ||
| Item 2 | ||
| Item 8 | ||
| ASSOCIATION | ||
| Item1 | ||
| Item 8 | ||
| EMOTION | ||
| Item 1 | ||
| COMMUNICATION | ||
| Item1 | ||
| Item 3 | ||
| INSTINCT | ||
| Item 3 | ||
| Item 4 | ||
| REGULATION | ||
| Item 1 | ||
| Item 4 |
Table 4. Number of behavioral problems observed bofore the treatment compared with the
number of behavioral problems
reduced after 18 months of treatment.
| BEHAVIORAL
PROBLEMS OBSERVED |
|
|
|
| STEREOTYPIC
BEHAVIORS | |||
| STEREOTYPED
MOVEMENTS | |||
| AGGRESSIVENESS | |||
| SELF-INJURIOUS
BEHAVIORS | |||
| TOTAL |
Table 5. Statistical significance of the results of the observations of spontaneous
communication after 12 months
of treatment.
| COMMUNICATION |
| ||
| FUNCTION | |||
| Ask something | |||
| Refuse | |||
| Express emotions | |||
| Give informations | |||
| Get informations | |||
| Social behaviors | |||
| MODE | |||
| Motor / gesture | |||
| Verbal | |||
| Pre-verbal | |||
| Object | |||
| Object on card | |||
| Photo / picture |
Table 6. Kind and number of 'words'
used before and after 18 months of treatment
| COMMUNICATION
Kind of "words" | ||
| WORDS | ||
| Motor / gesture | ||
| pre-verbal | ||
| Verbal | ||
| Object | ||
| Picture board | ||
| Photo / picture |