6.8 Integrated approaches
As we have seen, the individual needs of people with ASDs differ, depending on severity, age, life situation and coping strategies. At all stages, education and personal growth are as important as therapy per se. This section illustrates approaches that support and foster individuals within a broad educational and therapeutic framework. Such approaches seek to address key features of autistic disability (such as the need for structure, routine, and difficulty interpreting puzzling social messages), key features of autistic skill (for instance, precision, accuracy and tolerance of repetition) and the specific needs and outlook of the individual. The framework considered here is Treatment and Education of Autistic and related Communication handicapped Children (TEACCH), originally developed in North Carolina. It is widely used in UK school and home settings, and is one of several educational frameworks recommended by the NAS (see Box 15).
Box 15: The TEACCH framework
Key principles are:
Provision of structure, both in the person's environment and in the approach to teaching, which is typically one-to-one.
Emphasis on identifying and harnessing skills, particularly visual perception and memory, precision, accuracy and tolerance of repetition.
Evaluation of individual therapeutic needs on a regular basis, and the use of socio-cognitive and behavioural therapies as necessary.
Empowering parents by encouraging their full participation.
Emphasis on developing independence, and generalising from learning experiences in order to master a range of everyday situations.
Training for practitioners that emphasises a ‘whole person’ approach.
In implementing these principles a key technique is visual structuring of the person's environment and teaching. For instance, pictures, symbols, or objects may be set out on a TEACCH board, to help the person in structuring space, concepts, tasks and activities. The board may serve as a visual timetable by presenting photographs of activities in the order in which they are to be carried out.
An adult service manager reviewing the implications of TEACCH for different settings gives the following example of a home intervention.
A young lady living at home had become extremely anxious and nervous about changing her clothes, wanting to wear the same things all the time and seeming to find a security in doing so. Trying to encourage her to change had become a time of stress and tension for all concerned. TEACCH principles were applied as follows:
|Establishing visual boundaries||Seven small coloured baskets were organised – one for each day of the week – and labelled.|
|How much?||One complete set of clothes was put into each of the daily baskets.|
|When have I finished?||Once she was dressed in the clothes each day, the empty basket was upturned onto the other empty baskets.|
|What next?||At the end of the day the new basket of clothes was put out for the next day, and she put what she was wearing into the family laundry basket.|
Once the system was understood this young lady took to using it without problems, and nightly traumas about changing clothes faded away. Her independence has been developed by involving her in the setting up of the baskets for the week at the weekends.
(Robinson, 1997, pp. 8–10)
We can again evaluate TEACCH against the criteria given in Box 11.
Theoretical rationale: The approach draws on a range of theoretical insights, particularly the need to interpret inappropriate behaviour and anxiety in the light of both central coherence and ToM type difficulties. It also embraces established therapeutic principles from fields such as behaviour modification.
Methodological considerations: The success of TEACCH depends crucially on its adaptability to individual needs, and therefore documented cases of individual success – as illustrated by Box 15 – are relevant, as well as more systematic reviews of overall success. A recent longitudinal study by Persson (2000) tracked the progress of a group of autistic men living in a group home, who participated in TEACCH for the first time. Over a period of two years or more, there was clear evidence for improvement in behaviour problems, sense of independence and well-being, as well as a reduced need for staff monitoring.
Some practitioners express concern that TEACCH is an external ‘prop’ that, because it is not internalised, relies on the parent or carer to maintain it. Powell and Jordan (1997) state that children may regress in their behaviour and stress levels on moving away from a TEACCH-based system. As such, TEACCH is best suited to the needs of people with more extreme ASDs. However, Golding (1997) describes how TEACCH and other principles have been incorporated into an impressive programme for ‘high-functioning’ adolescents. The programme fosters the move from individual activity to group work in which participants provide each other with reflections and encouragement and offer mutual support. Golding's approach illustrates the benefits of a procedure tailored to the special therapeutic needs of ‘high-functioning’ individuals. They are encouraged to use their capacity for self awareness as a basis for sharing experiences with similar others, thus offsetting a sense of isolation.
Ethics: Like other integrated programmes, TEACCH has many positive ethical features. In particular, it is flexible to individual needs, considers dignity and general well-being, and, by empowering parents to administer the programme, reduces their feelings of helplessness.