Asia Pacific Journal of Pediatric and Child Health

Abstract Ref Number = APCP184

Invited Speakers

Autism Spectrum Disorder: Applied Behavioral Analysis versus Sensory Integration Therapy

Hardiono D Pusponegoro Department of Child Health, Faculty of Medicine, University of Indonesia RS DrCiptoMangunkusumo Hospital Jakarta

Is early diagnosis and early intervention important in autism spectrum disorder (ASD)? The answer is yes. Many publications stated that standardized early intervention delivered in a proper way can improve the prognosis of ASD.1–5The next question is what kind of intervention should be done? Intervention should be evidence-based, and considering the individual condition and development of the child.6Many intervention program have been developed, not all of them based on scientific evidence. We will discuss 2 most popular programs, sensory integration therapy (SIT) and programs based on applied behavioral analysis (ABA). Sensory Integration Children with autism show sensory problems and sensory dysfunction as one of the diagnostic criteria of ASD in Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).4, 7 Logically, the treatment is SIT. Sensory Integration Therapy has been reported to significantly improve the occupational profile and sensory profile.8–12 Our research result shows that SIT can also decrease negative behavior significantly.13 Sensory Integration theory has been developed by Ayres in 1972 to explain behaviors she observed in children with learning problems—behaviors that were not adequately explained by existing perceptual motor theories. The theory of SI postulates that adequate processing and integration of sensory information is an important foundation for adaptive behavior. Ayres showed how the interactions between the sensory systems—the auditory, vestibular, proprioceptive, tactile, and visual systems—provide integrated information that contributes to adaptive behavior and learning.14 The basic theoretical postulates of SI is: 1. Sensory information provides an important foundation for learning and behavior. 2. Sensory integration is a developmental process. 3. Successful integration and organization of sensory information results in and is further developed by adaptive responses. 4. The ‘‘just right challenge’’ provides the milieu for sensory integration to occur. 5. Childrenhaveaninnatedrivetoseekmeaningfulexperiencesfromtheirenvironment. 6. As a result of neuroplasticity, enriched experiences effect change in the nervous system. 7. Sensory integration is a foundation for physical and social engagement and participation in daily life activities and routines. Children with sensory dysfunction can be manifested as: 1. Sensory modulation dysfunction is an atypical response (over-responsiveness, under- responsiveness, or excessive seeking or avoiding) to sensory experiences or situations. 2. Somatodyspraxia includes poor ability to plan and execute novel motor actions associated with signs of poor perception of touch and poor body scheme/body 3. awareness . 4. Bilateral integration and sequencing deficit is defined as poor ability to coordinate 5. both sides of the body and atypical postural and ocular mechanisms associated with signs of inefficient processing and perception of movement and body position. 6. Somatosensory processing deficits are poor discrimination of tactile and proprioceptive information. 7. Vestibular processing deficit includes poor awareness and tolerance of gravity and movement through space. 8. Visuodyspraxia includes poor visual perception and visual motor integration. In delivering SIT, therapist encourage the occurrence of internal motivation to do some positive behavior in a certain sensory experiences. Therapist help by giving special sensory techniques to improve the capacity of the children to solve immediate situation.12 Applied Behavioral Analysis Applied behavioral analysis is a framework of many therapy programs. The target of ABA are increasing positive behaviors including cognitive and academic functions and and decreasing negative behaviors such as temper tantrum or self-injurious behavior. There are many programs based on ABA, for example Lovaas, Early Start Denver Model, Early Intensive Behavioral Intervention (EIBI), and Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP).15 7 basic principle’s of ABA are: 1. Applied: Applied interventions deal with problems of demonstrated social importance. 2. Behavioral: Applied interventions deal with measurable behavior (or reports if they can be validated). 3. Analytic: Applied interventions require an objective demonstration that the procedures caused the effect. 4. Technological: Applied interventions are described well enough that they can be implemented by anyone with training and resources. 5. Conceptual Systems: Applied interventions arise from a specific and identifiable theoretical base rather than being a set of packages or tricks. 6. Effective: Applied interventions produce strong, socially important effects. 7. Generality: Applied interventions are designed from the outset to operate in new environments and continue after the formal treatments have ended. In the beginning of ABA session – different from SIT – it needs cooperation of the children to follow therapist instructions. This can create problems because children do not like to sit and follow instructions. The most important ABA principle is the antecedent-behavior-consequence (ABC), meaning that all behaviors have antecedent, the children show specific behavior because of the antecedent stimuli, followed by consequences of that behavior. The most important ABA tools is reinforcement or reward if the children can do something good or follow instructions. Punishment including verbal punishment like “no” to stop negative behavior is still done in Lovaas method, but not done anymore in modern ABA program such as verbal behavior, because punishment will not ha a long lasting effect. In t=he Lovaas method, ABA is delivered 40 hours a week. Today, that paradigm has shifted. ABA can be done in therapy center or at home by parents, so the total hours will be more or less 40 hours.16 Some parents think that ABA is very strict and will turn the child to become a robot. It is not true if you know how to deliver a good ABA program. In advanced state, a program such as Pivotal Response Treatment (PRT) can be done in a playful situation and initiated by the children.17 The goal of PRT is the improvement in communication and social function while decreasing negative behaviors. PRT is directed to pivotal areas such as motivation, response to multiple clues from the environment, self-management and initiation of social interaction. By improving pivotal areas, children can develop social, communication, behavior and academic functions.17 A systematic review from Cochrane showed that EIBI can improve adaptive function, decrease autism symptoms, increase IQ and increase expressive and receptive function,5decreasing anxiety18and improve sleep.19EIBI showed a long lasting effects.20Unfortunately, if the therapy is stopped than the autism symptom can occur again.21 Parents participation is encouraged, and the result of therapy will be better if parents are trained and involved in the therapy process.1 Anakku Check My Child Clinic experiences In Indonesia, the diagnosis of ASD is often made in children aged 18 months – 2 years. At this age, the children like to play and exploring the environment. At this time, doing SIT is easier and more fun compared to ABA. Mild autism cases often show improvement in adaptive functioning22 and less negative behavior.13 It should be remembered that SIT cannot improve academic function. If the children already show better interaction and less hyperactive, ABA therapy should begin even though they are still 3 tears old. We still see children aged 5 years continue SIT. I think SI dysfunction cannot be 100% corrected. If the sensory function is enough for everyday life, it is enough for the children. ABA therapy can be started with Discrete Trial Training, followed soon with VB-MAPP. To children who already in advanced state, PRT can be done for generalization. ABA can be delivered in playful situation, not only sit near the wall and cannot move. There is claim that SIT should be done by occupational therapist SIT and ABA should be done by Registered Behavior Technician (RBT), Board Certified Assistant Behavior Analysts (BacBA) orBoard Certified Behavior Analysts (BCBA). The purpose of this claim is to guarantee that the therapy will be delivered properly with a a=standard technique. But on the other side this claim can cause increase in the expense of services, commercialization of therapy, restriction interaction between certified and non-certified therapists, and a potential legal battles.23Indonesia does not have enough therapist. It is more important to focus on kind of therapy, delivery of therapy and result of therapy. 23. In Anakku Check My Child Clinic, the result of therapy is controlled by child neurologist, child psychologist and medical rehabilitation doctor every 3 months. Our clinic maintain therapy based on criteria’s: 1) parents should know what happened in therapy room. And therapy should not done in a locked room, 2) children should enjoy the therapy sessions, nor crying continuously, 3) after every session, therapist should have a discussion with parents about the result of that session and what should be done at home, 44) a standard report should be delivered every 3 moths, 5) children most show good progression every 3 moths and 5) parents training are done in order to deliver therapy at home.

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