Dr. Mona Tawakkul Elsayed

Associate Prof. of Mental Health and Special Education

Interventions Supp

Interventions Supported by Significant Scientific Evidence






Applied Behavior Analysis (ABA)








ABA is defined as the process of applying behavioral principles to change specific behaviors and simultaneously evaluating the effectiveness of the intervention. ABA emphasizes both prevention and remediation of problem behavior. Significant attention is given to the social and physical environment, including the antecedent conditions and consequences that elicit and maintain behavior. Numerous empirical studies have documented the effectiveness of ABA with individuals with ASD. These interventions should typically be provided under the supervision of a trained behavioral psychologist or behavior analyst. Research suggests that the best outcomes occur when ABA is initiated early in development, preferably prior to 5 years of age. There is an ongoing debate about the amount of ABA needed in order for it to be optimally effective, with recommendations typically ranging from 15 to 40 hours per week, depending on whether ABA is being applied to comprehensive educational programming in the schools or to a targeted behavioral treatment program. Training caregivers to provide ABA in the home or community settings is an important part of most ABA programs, and teleconsultation is proving to be a useful and effective strategy for providing ABA in rural or other underserved areas. In fact, ABA delivered through as little as 1 hour per week of parent training can be effective in reducing behavior problems and building social communication in children with ASD. This intervention can be used with all ages and ability levels, and ABA principles are often included as part of effective early intensive intervention programs. The following specific ABA interventions are described in greater detail (although this is not an exhaustive list): 13



Discrete Trial Training (DTT) is grounded in behavioral learning theory and applied behavior analysis, and it is sometimes referred to as “Lovaas therapy” in reference to Ivar Lovaas at UCLA, who was a strong early proponent of using DTT with children with autism. Using this intervention, a discriminative stimulus is presented, the child responds, and then the child receives a consequence (e.g., reward) based on the response. DTT often incorporates the use of errorless learning, shaping, modeling, prompting, facing, correction, and reinforcement to encourage skill acquisition. It is especially well-suited for skills that can be taught in small, repeated steps. Research indicates that DTT can produce powerful behavioral outcomes in the areas of language, motor skills, imitation and play, emotional expression, academics, and the reduction of self-stimulatory and aggressive behaviors. Special training is necessary to deliver DTT interventions, and hiring a DTT trained therapist to provide 25-40 hours of therapy per week can be expensive. This intervention can be used with all ages and ability levels.


Functional Communication Training (FCT) is a behavioral methodology that replaces disruptive or inappropriate behavior with more appropriate and effective communication. After the communicative “functions” of disruptive behaviors are determined through functional behavioral analysis, socially appropriate behaviors are taught as replacements for problem behaviors. FCT has a strong research base, especially using single-subject research designs, and FCT has been shown to significantly reduce problem behavior and to increase communication and social interaction. This intervention is very effective with young children with limited cognitive and language skills, but it can be used with individuals of all ages. When delivered through weekly training sessions with parents/caregivers and their children, FCT can be a very effective and efficient intervention strategy for reducing problem behavior and increasing communication and social behavior.


Pivotal Response Training (PRT). The NPDC describes PRT as a systematic method for applying the scientific principles of ABA. PRT builds on a child’s initiative and interests, which makes it particularly effective in developing communication, play, and social behaviors. This strategy enhances the pivotal learning variables of motivation, responding to multiple cues, self-management, and self-initiation, which serves to influence target behaviors within a natural setting. Research has supported the effectiveness of PRT in increasing motivation and improving language and play skills. It is recommended that PRT be implemented by caregivers and teachers in natural contexts; it is considered cost- and time-efficient. This intervention can be used with preschool-aged children through adults with mild cognitive impairments and with those who have at least a minimal level of receptive and expressive language. 14


Antecedent-Based Interventions. In applying ABA techniques, it is important not only to provide reinforcement or punishment after a behavior has occurred, but also to set up antecedent conditions that increase the likelihood of success and reduce the probability of problem behaviors occurring. Specific antecedent procedures that are frequently used for ASD include choice, behavioral momentum, cueing and prompting, modifying task demands, errorless learning, priming, non-contingent reinforcement, and time delay. These types of interventions can be used with all ages and ability levels.


Other Specific ABA Strategies. A wide range of specific ABA techniques have received significant empirical support, and comprehensive treatment programs typically make use of a “package” that includes several of these evidence-based ABA strategies. Examples of these methods include prompting, time delay, reinforcement, extinction, task analysis, response interruption/redirection, and differential reinforcement.






Early Intensive Interventions








Intensive early intervention programs that provide ABA strategies, often in combination with developmental approaches, have been shown to produce improvements in behavior, communication, and cognitive abilities. Lovaas-based approaches (as described above in the discussion of discrete trial training) are the most widely used and have the strongest research base thus far for programs of this type. A randomized controlled trial of the Early Start Denver Model, which uses a combined ABA-developmental model, has also produced positive outcomes for young children with ASD. A successful randomized trial for the Learning Experiences and Alternative Program for Preschoolers and Parents (LEAP) has been completed as well. Although these studies are not without methodological limitations, the NAC review designated comprehensive behavioral treatment for young children using programs of this type as an “established treatment.”








Social Skills Training








Deficits in social interaction are core problems in ASD. There is good evidence that interventions to directly train social skills can be effective, and increasing prosocial behaviors is typically a primary outcome in ABA interventions. Both the NCPC and the NAC standards also consider the use of social narratives/stories to be useful tools for social skills training. The use of peer-mediated interventions to build social skills is well established as well. There is evidence that specific aspects of social interaction (e.g., eye contact, joint attention, verbal greetings, etc.) can be learned with focused training. The NCPC analysis documents solid evidence for the effectiveness of social 15





skills training groups, although the NAC standards consider a “social skills package” to be an emerging rather than well-established practice.








Cognitive-Behavioral Therapy








The scientific basis for the use of cognitive behavior therapy (CBT) with adolescents and adults with mood or adjustment problems is extensive and diverse. In fact, CBT is one of the most widely used non-pharmacologic treatments for individuals with mental and emotional disorders, especially depression, and its use with individuals with autism spectrum disorders is growing. CBT focuses on replacing negative or ineffective patterns of thought and behavior with structured strategies that are effective in improving mood and adaptive functioning.


In the autism research base, the scientific evidence for the effectiveness of "self-management," a type of CBT, is described by the NPDC-ASD as follows: “Self-management interventions help learners with ASD learn to independently regulate their own behaviors and act appropriately in a variety of home, school, and community-based situations. With these interventions, learners with ASD are taught to discriminate between appropriate and inappropriate behaviors, accurately monitor and record their own behaviors, and reward themselves for behaving appropriately. As learners with ASD become more fluent with the self-management, some of the implementation responsibilities shift from teachers, families, and other practitioners to the learners themselves.”


The ASAT, NAC, and NPDC treatment reviews all list self-management as an intervention with a well-established evidence base. Other forms of CBT have not been studied as extensively in ASD as has self-management, but scientific data supporting CBT have also been established by studies that adapt traditional CBT approaches to ASD populations for the management of anxiety, depression, and social deficits. CBT is especially appropriate for use with older children and adolescents or adults with Asperger's syndrome or high functioning autism, for whom the cognitive demands of the therapy are manageable. To maximize effectiveness, it is important to rely on structured behavioral principles as much as possible and to use higher-level cognitive strategies only to the extent allowed by the cognitive abilities of the client/patient.








Medication








The use of pharmacological treatments for symptoms of ASD is both common and challenging. Several psychiatric disorders in children are successfully treated by medications, and many of these disorders have symptoms that overlap with those seen in children with ASD (e.g., hyperactivity, inattention, tics, obsessive-compulsive behaviors, depression, anxiety, sleep problems, etc.). However, there are no medications that directly treat the social and language impairments seen in individuals with ASD. The medications used most frequently for children and adults with ASD include 16





antipsychotics (e.g., risperidone), selective serotonin reuptake inhibitors (SSRIs) to treat mood and repetitive behaviors, and stimulants and other medications used to treat attention deficits and hyperactivity. The evidence base is good for using atypical antipsychotics (e.g., risperidone and aripiprazole) to treat challenging and repetitive behaviors, but there are also significant side effects associated with the use of these drugs. There are some well-designed studies supporting the use of SSRIs and stimulants with patients with ASD, but the evidence base is not as strong as for the antipsychotic medications.








Other Evidence-Based Interventions








Several other types of interventions for ASD have an established evidence base and are used in combination with other effective treatments. The NCPC describes many of these in detail, but they are also described briefly below:



Augmentative and Alternative Communication (AAC) devices and tools can help




compensate for expressive communication deficits. These interventions range from the use of sign language to picture systems and more complex electronic communication devices. Many children with autism will not develop functional speech, and the use of AAC is indicated in this population to enhance communication abilities. This type of intervention can be used with individuals with communication deficits at any age.



Picture Exchange Communication System (PECS) is an augmentative communication strategy designed for individuals with expressive language deficits. Individuals are trained to exchange picture cards for desired items, which the therapist pairs with a verbal label for the item. In addition to targeting communication skills, PECS also reinforces attempts to initiate social contact in children with ASD. Empirical studies have documented an increase in functional communication following this intervention, especially when used as part of ABA treatment. This therapy can be used at any ages and all ability levels.


Modeling, especially using video technology to record actions for later review, can provide a visual model to assist in building skills in communication, play, or social interaction.


Visual Supports, including the use of schedules and structured work tasks presented visually, are effective for individuals with ASD across many work and learning environments.


Computer-Aided Instruction can assist individuals with ASD in learning communication and academic skills.


Parent-Implemented Intervention is a core component of many evidence-based interventions for ASD, including functional communication training and social skills training. 17




Interventions with Promising or Emerging Evidence






Developmental Relationship-Based Treatment








These treatment programs may be referred to by other names such as Floortime, DIR (Differential, Individual differences, Relationship-based), or Relationship Development Intervention (RDI). Floor time seeks to facilitate the acquisition of social-communicative skills through intensive child-directed play and positive interactions. It is recommended that this strategy be integrated with other therapies (e.g., speech therapy and occupational therapy). Floor time has become a popular intervention among parents, but it continues to lack scientific evidence. This treatment is intended for young children, but can be used in some form with all ages and ability levels.








Play Therapy








Learning play skills is important for children with ASD, and providing guided opportunities for play-based interactions with peers is an important part of social skills training, which is an evidence-based intervention. However, traditional insight-oriented play therapy, where the child is expected to “act out” or “work through” internal conflicts, is generally not effective for children with ASD. Some play-oriented strategies can be helpful in fostering social communication when used to complement other evidence-based interventions.








Supportive Therapies








There are several types of “supportive” therapies that have strong proponents and some data to suggest that they may be effective with some individuals with ASD. The National Autism Center review designated music therapy and massage therapy as emerging treatments. Other therapies with some support include art therapy and pet/animal therapy although the scientific evidence supporting these interventions is not strong. Even without additional scientific evidence to support these therapies, it is likely that activities that are fun and engaging will provide opportunities for reinforcement, relaxation, and social interaction for individuals with ASD.






Interventions with Limited Scientific Evidence






Sensory Integration (SI)








The use of sensory integration (SI) therapy for treatment of ASD has been both popular and controversial. Many children with ASD are believed to have a form of sensory integration dysfunction, defined as neural dysfunction that causes the nervous system to inefficiently receive and process incoming information, which may lead to hypersensitivity or hyposensitivity to sensory input, unusually high or low activity levels, coordination problems, delays in speech or motor skills, and/or behavior 18





problems. In SI, a child’s individual sensory needs are evaluated, and a program of sensory therapies (e.g., riding scooter boards, swinging, jumping on trampolines, wearing weighted vests, wrapping in fabric) is developed and prescribed as a “sensory diet.” Most SI therapy is implemented by occupational therapists. Proponents of this therapy argue that sensory integration therapy results in improved mental processing and organization of sensations, although this is difficult to measure objectively. Despite its widespread use, SI is most often considered a “complementary and alternative medicine” (CAM) treatment rather than an accepted treatment methodology, and the neurodevelopmental theories underlying SI are not generally accepted by medical scientists. The American Academy of Pediatrics (AAP) has summarized the scientific findings on SI by stating that “the efficacy of SI therapy has not been demonstrated objectively.”


Four out of five of the primary data sources analyzed for this study do not consider SI therapy as an evidence-based treatment for ASD. Although Simpson’s review was the only one to list SI as a potentially “promising” practice, this assertion was apparently based on its widespread use and not on the adequacy of scientific data to support it. In fact, Simpson summarizes the data on SI as follows: “SI techniques have not been thoroughly investigated for scientific effectiveness” and “minimal research has reported positive effects of SI therapy to date.” Consistent with this conclusion, the ASAT review of the SI literature concludes that there are too few well-designed studies to draw conclusions and that professionals should present SI as “untested.” Although there is some evidence that active gross-motor activities may affect children with ASD differently than table-based fine-motor activities, a recent published study on the effects of weighted vests, a common part of SI therapy for ASD, failed to find outcomes supporting SI treatment.


Given the scarcity of scientific evidence supporting SI (and some evidence that it is not effective), the use of SI therapy for ASDs must be considered an intervention with “limited scientific evidence” currently. However, it is important to recognize that other OT treatments focused on improving practical functions (e.g., ADLs, feeding, writing, etc.) are a mainstay of therapy for a range of neurodevelopmental disorders, and children with ASDs should not be excluded from access to those interventions. Also, some of the activities emphasized in SI therapy may benefit children in becoming more physically active or accepting a wider range of sensory experiences when used as part of a comprehensive ASD intervention program. As the AAP states, “ ‘Sensory’ activities may be helpful as part of an overall program that uses desired sensory experiences to calm the child, reinforce a desired behavior, or help with transitions between activities.” However, SI theory and specific effects of SI-based therapies lack supporting evidence from well-designed studies. 19







Auditory integration training (AIT)








AIT is a controversial intervention that purports to remediate problems with sound sensitivity and auditory processing, with the result of improved behavior, communication, and quality of life. Although several studies have been conducted, there is currently no scientific evidence that AIT retrains auditory systems of individuals with ASD with the result of improved functioning.








Nutritional Supplements








Megavitamin therapy is based on the hypothesis that symptoms of ASD may be related to biochemical errors resulting in nutritional deficiencies. Typical supplements for this population include vitamin B6, magnesium, vitamin C, and vitamin A. There are several reports that megavitamin supplements may benefit some children with ASD, but this treatment currently lacks scientific support through well-controlled research. Although vitamins can be obtained over the counter, it is recommended that a physician be involved if this intervention is being considered. There are significant questions about the safety of large doses of certain vitamins.








Gluten- and Casein-Free Diet








Gluten is a protein found in plants including wheat, barley, oats, rye and their derivatives. Casein is a protein found in cow’s milk. In some severe cases, an inability to properly metabolize these proteins can lead to serious gastrointestinal or neurological problems. It has been proposed that ASD symptomology may be associated with this process, and thus a gluten- and casein-free diet has been suggested as a treatment for ASD. A few studies have suggested that long-term elimination of gluten and casein from a diet may result in behavioral improvements in children with ASD. It is strongly recommended that a physician be consulted to test for possible food allergies prior to beginning this diet. This type of intervention can be very stressful for the family and has yet to be established as an empirically valid intervention.








Facilitated Communication (FC)








Facilitated communication was designed to be an augmentative communication strategy that involves the use of a “facilitator” who gently provides hand-over-hand physical assistance to individuals with disabilities as they type (or point to pictures) to communicate. This method can be used with individuals of all ages who are otherwise unable to effectively communicate using speech. Facilitated communication is a highly controversial technique due to concerns that the facilitator may actually guide the individual’s responses. Testimonials have reported this to be a highly effective intervention, while blinded objective analyses have consistently failed to find empirical support for this method. In addition, some false claims of abuse have been initiated 20





through FC, and many courts no longer allow testimony through FC to be admitted as evidence in court.






Interventions that are Not Recommended






Holding Therapy








Holding therapy is designed to restore and strengthen the bond between the child and caregiver through forced physical proximity and eye contact. The child is expected to initially reject this treatment but will then develop closeness with the caregiver after realizing that his/her anger cannot break the parent-child bond. This treatment has several risks, including possible physical and psychological harm to the child and parent, and it has not received empirical support.








Secretin








Secretin is a gastrointestinal peptide hormone that has received attention as a potential “cure” for autism. Controlled research indicates that secretin has no benefit for individuals with ASD, and individuals with ASD should not be exposed to a treatment that has been shown to not be effective.








Chelation for Neurotoxicity








It has been hypothesized that environmental exposure to toxic metals or to a mercury compound (thimerosal) used in some vaccinations may cause or contribute to the development of autism. Despite empirical evidence that does not support this this theory, along with the removal of thimerosal from virtually all vaccines, many parent groups continue to believe that vaccines cause autism. Chelation therapy, a potentially dangerous treatment for mercury or other heavy metal poisoning, is sometimes used with children with ASD. Some parents have chosen not to vaccinate their children due to the fear that vaccinations may cause ASD, thus leaving them vulnerable to developing several preventable diseases. Because of the dangers of chelation and the lack of a medical reason to perform the procedure, chelation for ASD in the absence of high levels of heavy metals is not recommended.






Using these Findings for Treatment Planning






Based on this review of ASD interventions, it is clear that intensive, highly structured programs based on the principles of applied behavior analysis are the gold standard for autism treatment. Early intervention is effective, so it is essential that the primary focus of parents and professionals is on the child’s acquisition of communication, social, play, and academic skills. If biological interventions are attempted, medical professionals should be involved and detailed data should be taken to document the effects, both positive and negative, of the biological intervention on the 21





child. Certainly, scientifically-based practices are most strongly recommended, but several interventions designated as “promising” may also be beneficial for some individuals with ASD. Currently, interventions labeled as having “limited supporting evidence” or “not recommended” cannot be recommended as ASD treatments due to lack of empirical support and/or risk for harm. It is likely that no single intervention is going to be sufficient in treating the symptoms of ASD; therefore, it recommended that an individualized program of services be developed to meet the child’s developmental, educational, behavioral, emotional, and social needs. A comprehensive treatment program for a child with ASD should include behavioral, speech and language, and educational interventions; pharmacological treatment of specific symptoms may also be appropriate. The effectiveness of all interventions a child receives should be evaluated regularly and adjusted as necessary. Finally, it is clear that the field of ASD would benefit significantly from continuing research into the effectiveness of proposed ASD interventions.

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المهارات الناعمة

المهارات الناعمة مفهوم يربط بين التكوين والتعليم وبين حاجات سوق العمل، تعتبر مجالاً واسعاً وحديثا يتسم بالشمولية ويرتبط بالجوانب النفسية والاجتماعية عند الطالب الذي يمثل مخرجات تعلم أي مؤسسة تعليمية، لذلك؛ فإن هذه المهارات تضاف له باستمرار – وفق متغيرات سوق العمل وحاجة المجتمع – وهي مهارات جديدة مثل مهارات إدارة الأزمات ومهارة حل المشاكل وغيرها. كما أنها تمثلالقدرات التي يمتلكها الفرد وتساهم في تطوير ونجاح المؤسسة التي ينتمي إليها. وترتبط هذه المهارات بالتعامل الفعّال وتكوين العلاقات مع الآخرينومن أهم المهارات الناعمة:

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مخرجات التعلم

تصنيف بلوم لقياس مخرجات التعلم

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التعلم القائم على النواتج (المخرجات)

التعلم القائم على المخرجات يركز على تعلم الطالب خلال استخدام عبارات نواتج التعلم التي تصف ما هو متوقع من المتعلم معرفته، وفهمه، والقدرة على أدائه بعد الانتهاء من موقف تعليمي، وتقديم أنشطة التعلم التي تساعد الطالب على اكتساب تلك النواتج، وتقويم مدى اكتساب الطالب لتلك النواتج من خلال استخدام محكات تقويم محدودة.

ما هي مخرجات التعلم؟

عبارات تبرز ما سيعرفه الطالب أو يكون قادراً على أدائه نتيجة للتعليم أو التعلم أو كليهما معاً في نهاية فترة زمنية محددة (مقرر – برنامج – مهمة معينة – ورشة عمل – تدريب ميداني) وأحياناً تسمى أهداف التعلم)

خصائص مخرجات التعلم

أن تكون واضحة ومحددة بدقة. يمكن ملاحظتها وقياسها. تركز على سلوك المتعلم وليس على نشاط التعلم. متكاملة وقابلة للتطوير والتحويل. تمثيل مدى واسعا من المعارف والمهارات المعرفية والمهارات العامة.

 

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