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- What is Autism
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Autism & Diagnosis
Developmental Milestones are very clear in typically developing children and it is critical that we monitor developmental milestones in each child especially from birth to three. The deficits or delays that a child with autism demonstrates are usually very clear making a confident diagnosis of autism accurate by the age of 18 months.
It is also very important to note that the younger a child is when autism is identified, the increased potential for the child to catch up as:
- The developmental gap is smaller;
- The inappropriate behaviours a child may demonstrate are not as established in comparison to an older child
- Most importantly a younger child’s brain is still developing and much easier to rehabilitate.
There is a significant increase in early childhood developmental disorders over the years in comparison to previous generations and therefore it is always better to be ‘safe than sorry.’ There is no harm or danger in seeking a professional diagnosis but there is a significant risk to ignore red flags and symptoms as time is of the essence in treating autism as early as possible.
Ultimately, it is not so much about the label but the diagnosis in order to provide the most effective treatment as soon as possible. We do understand that unfortunately, there is still a stigma when it comes to individuals of different abilities. As we strive to creating and influencing a more accepting society, we do maintain strict privacy and confidentiality for all our clients. It is also important to note that almost 50% of individuals with autism who have received good quality ABA treatment will often not meet sufficient symptoms of autism any longer.
The symptoms of autism and the challenges that are present itself in autism are quite specific and an experienced clinician conducting the diagnostic evaluation will evaluate based on typical developmental milestones which have factored in slight differences based on personality or culture or rate of learning.
Typically if a child is just ‘shy’, he would still be able to articulate fluently with people he is comfortable with or in a home setting. If a child is just very ‘particular’ or ‘choosy’ then the other symptoms of autism would not present itself – e.g. the challenges with language and communication as well as socialising with others.
This is the reason why it is very important for a thorough diagnostic evaluation utilising the DSM-5 be conducted by an experienced clinican over a 2-3 hour period in order to rule out other differential diagnoses or the possibility of comorbid disorders.
Although many movies and TV shows have highlighted individuals with autism who have genius talents, only 10% of the autism population are ‘savants’ which are individuals who have these rare genius talents, be it music, art or mathematics.
It is important to note that autism is a spectrum disorder and some individuals are more affected than others and that autism impacts language, social skills and presents challenging behaviours in most of those affected by it.
Children with autism have the potential to live as typical a life as possible with the right intervention. As autism is a spectrum, some individuals are affected minimally, moderately or severely.
Based on the level of autism in a child as well as the treatment they receive, research shows that almost 50% of children who receive good quality ABA therapy at an early age are able to catch up to their developmental age. These children may still require support socially in some areas as well as at certain critical stages of their lives such as school transitions and puberty.
The other 50% who are not able to catch up are still able to learn to their best potential which includes reducing challenging behaviours, increasing functional communication, independence and overall life skills.
The most important is that every child with autism receives sufficient support in order for the individual and their family to live as meaningful a life as possible.
It is important to find out more about the research:
- Is it truly scientific research, were the reliability and validity scores met for the research?
- Is it published research in reputable journals?
- Has this research been reviewed and replicated?
Most importantly as a parent, does the treatment make common sense and does it address all the complex challenges that come with autism.
Initially, most children with autism do not present the foundational skills for learning – i.e. the ability to cooperate, imitate or attend. These 3 foundational skills are critical for a child to learn additional skills that are more complex such as speech.
When in a group environment (such as a daycare or school), even the best teacher is unable to give a child with autism the full attention he requires in order to thoroughly occupy his time, teach him new skills and prevent him from participating in self-stimulatory behaviour.
Furthermore, our expectation would be for a child with autism to be able to learn naturally from the group but this a core deficit of most children with autism as they are not able to ATTEND (e.g. they are focused on other things) nor IMITATE from others (e.g. they are in their own world or not interested in other children or teachers) and so the child may end up being physically present in the school but not maximising their learning potential.
Often times, when a child is not ready for a group environment, we may see an increase in inappropriate behaviour such as self-stimulatory (stimming), aggressive behaviour towards others or learning that they just go to school but not have to cooperate or attend.
This is often recommended and can be effective if practiced intensively and by a good quality speech/occupational therapist.
At EAP, our comprehensive programme targets speech and language and more importantly functional communication right from the start. The difference would be that instead of 1 hour of Speech Therapy a week, we would implement speech targets throughout every single hour 35 hours a week.
We often work together with good quality Speech Therapists and Occupational Therapists to incorporate additional strategies they may have into our ABA therapy hours.
Children with autism have a small window of opportunity to learn rapidly. As clinical practitioners, we are fighting against time to help our children catch up as quickly as possible. It is of a child’s best interest that he receive a strong treatment programme that covers all areas of development systematically and as consistently as possible in order to promote rapid learning.
Having an eclectic multiple practitioner approach can be counterproductive as each practitioner has their own priorities and can be ultimately confusing for the child. As the old saying goes, ‘Too many cooks may spoil the soup.’
Well in general good quality ABA treatment is expensive mainly because:
- ABA treatment is provided on a one-to-one basis;
- Additionally the efficacy of ABA is dependent on the intensive hours, ideally 35 hours a week;
- Each programme needs to be personalised to the individual child, requiring high quality clinical expertise and more time;
- In order to ensure the quality of the ABA programme, multiple levels of supervision is required;
- This includes BCBA qualified clinicians from the USA.
E.g. Center XYZ
1. Treatment Approach
Good Quality Applied Behavioural Analysis (ABA) that includes the following characteristics:
A version of ABA that may have been learned through various workshops, or being a freelance therapist or intern.
The quality of ABA practice may be compromised by lower hours, group-based learning, poorly-trained staff and low supervision hours.
Alternatively the center may be practicing an eclectic treatment approach.
2. ABA Practice & Governance
EAP's Curriculum has been inherited from our parent company Wisconsin Early Autism Project and is a combination of The Lovaas curriculum which has 6 Phases of Learning and 7 Key Areas of Priorities as well as adapted from years of our parent company's experiences and a library of additional complementary materials (e.g. Big Book, A Work in Progress, More Than Words, Teach Me Language, Early Start Denver Model, Social Detective Series, etc.).
Our curriculum is constantly being refined and developed as our clinical quality and expertise increases as well as in consultation with our International BCBA Consultants.
Screening & Training of Clinical Therapy Team
EAP conducts a thorough 3-level screening (only 10% of job applicants to EAP annually are hired). All of our EAP therapists are required to go through intensive initial training as well as ongoing training and supervision throughout their tenure at EAP.
For all therapists, an initial training including 20 hours of classes and 3 weeks on hand-held training is required before starting work with a child with autism after which regular fortnightly if not weekly supervision is provided through regular overlaps and team meetings. Each therapist also attends monthly Team Clinics with their EAP Supervisor.
Additionally EAP provides 3 Levels of Internal Certificate Training that takes place 6 times a year over a period of 3 years. 2 of the Annual Certificate Trainings are conducted by our International BCBA Consultants.
EAP Supervisors are required to complete a minimum of 1500 therapy hours under EAP supervision before they are eligible to become Supervisors. Shortlisted Supervisors then enroll in EAP's 6 month Supervisor training consisting of over 80 hours of classes over a 20 week period afterwhich they meet weekly with their Senior Supervisor, and have bimonthly if not monthly Senior Supervision meetings for the children on their caseload.
All Supervisors and Senior Supervisors meet fortnightly for Clinic Meetings in order to calibrate clinical recommendations as well as with our BCBA International Consultants during Progress Reviews.
Multiple Levels of Supervision
EAP's Senior Clinical Team Combined Experience of 32 years:
EAP's senior clinic team oversees the quality of ABA treatment provided at EAP and altogether has a combined experience of 32 years of clinical practice in the field of ABA.
Each child at EAP is assigned a team of therapists who are supervised by a Supervisor on a fortnightly basis and a Senior Supervisor on a bimonthly basis in addition to the WEAP Progress Reviews twice a year.
The reason for the multiple levels of supervision is that the autism spectrum is very wide and the diversity each child has in terms of strengths, challenges and age requires a high level of experience.
Additionally consistent multiple levels of supervision has been proven to ensure the highest quality of services provided.
Parents have reported to us that often times, a "Supervisor" or "Consultant" is assigned to their child but may only visit once a month. Freelance therapists are then left to figure out solutions on their own and may be doing repetitive and unproductive trials for extensive periods of time.
Often times there is insufficient information on the qualification, training nor experience of the therapists and Supervisor.
Documentation & Clinical Records
It is international best practice to have thorough documentation and storage of clinical records. This includes:
Standardised International Developmental Assessments
It is also international best practice that every child in a good quality ABA Programme participate in an annual thorough Developmental Assessment which consists of an IQ assessment, language assessment as well as adaptive behaviour scales assessment.
These scores provide an accurate baseline score and these assessments are conducted every 12 months in order to accurately monitor a child's progress.
The nature of ABA therapy is that it can be conducted in any location - be it our EAP center, a child's home, daycare, school or even vocation. EAP's priority has always been to invest into our clinical team of Supervisors and therapists who are the key to each child's development.
At the same time, at our center, EAP has emphasised the safety and security of our children and team and this has been our utmost priority.
Our facility meets the DBKL requirements of a child-care center with sufficient fire escapes as well as international best practices of fire extinguishers, regular fire evacuation practices, smoke alarms, CCTVs, security guards, and all our staff are required to undergo First Aid and Fire Evacuation training.
The concern would be the governance of practice. When any therapist in any field works on their own without ongoing supervision and training, there is a limitation to their level of knowledge and expertise. This becomes particularly risky in the field of autism as the spectrum is so wide and it requires years of supervised experience in order to become an expert in the field.
At EAP, each of our therapists adhere to a strong code of ethics and practice and are regularly supervised during fortnightly overlaps and team meetings in order to ensure clinical quality. Each therapist attends monthly Team Clinics where further clinical training is provided as well as EAP’s 3-level Certified Training which takes place 6 times a year.
Our EAP therapists are supervised by EAP Supervisors who report weekly to EAP Senior Supervisors who then report to our international BCBA Consultants.
It is our multiple-level of supervision that ensures the provision of good quality ABA therapy and we are not willing to risk the progress of the children entrusted to us by compromising this quality.
The practice of ABA has evolved signficantly over the last 40 years and incorporates a lot more naturalised teaching, naturalised reinforcement, a significant emphasis on play and generalisation as well as incorporating other complementary techniques.
Additionally unfortunately due to the lack of governance of ABA practice in Malaysia, when ABA is practiced by individuals who are not sufficiently supervised and trained as well as lacking supervised experience, they may practice certain elements of ABA such as the discrete trial protocol which they may have learned in a workshop.
Good quality ABA should be practiced in natural and generalised environments and maximising the learning potential of every child.