Service Delivery: Amount of Direct Intervention
Review of research emphasizes the importance of early, intensive intervention. The number of hours of service in a home, school, or community setting is determined through the IFSP/IEP process. The amount of direct intervention is customized to meet the unique needs of the child and family.
Intervention programs are designed to include direct instruction to the child and training and participation of family members and caregivers. Services are modified to meet the changing needs of the child and family.
- Amount of Direct Intervention for Children of Infant and Toddler Age (Birth through Two Years)
- Amount of Direct Intervention for Children of Preschool Age (Three through Five Years)
- Amount of Direct Intervention: Research Findings
Amount of Direct Intervention for Children of Infant and Toddler Age (Birth through Two Years)
Although intervention models for infants and toddlers who have autism will include many of the elements outlined in this section, they will also have unique features that recognize the developmental ages and stages of the younger child. The importance of the child-caregiver interaction during this period of development may necessitate increased intervention in natural settings with the caregiver as interventionist. Program design includes emphasis on attention and response to social aspects of the
child’s everyday activities and routines in the natural environment (Dawson and Osterling, 1997). The professional serves the role of coach in training family members to maximize initiation, engagement, and interactions.
Guidelines for the amount of direct intervention with infants and toddlers varies in accordance with different program designs. Gail McGee, researcher and director of the Walden School at Emory University, reported that for toddlers the “Hours of engaged time are key to children’s learning, and more hours of engaged time is better than less.” (McGee, et al, l999). The Walden School at Emory University provides both school and home-based services for toddlers with autism and McGee emphasizes the important role of family members in implementing the child’s intervention plan stating, “well prepared family members (including parents, grandparents, siblings, and others) are capable of adding substantially to the number of intervention hours that their child receives each week.” (McGee, et al, 1999). Rogers (1996) states, “Children with PDD/autism appear most able to benefit when intervention is begun very early, between ages two and four, making far more progress than older children receiving the same interventions, and when interventions were intensive, including 15 or more hours per week of focused treatment with low child to adult ratios.”
Amount of Direct Intervention for Children of Preschool Age (Three through Five Years)
As children enter the preschool years, treatment may be more focused on learning school-readiness behaviors and skills. Carryover of skills taught in school-based settings to the home and other community environments and addressing other non-school related deficits also remain imperative to effective programming. A review by Dawson and Osterling (1997) evaluated eight model early intervention programs for preschool children with autism. The range of school-based hours per week was from 15 to 40 with an average of 27 hours. All of the programs included a family training and participation component which added to the total hours. The researchers surmised that the actual hours of intervention were probably even greater. Dawson and Osterling report that, “Although it is not possible to conclude from these data what is a necessary and sufficient number of hours per week of school-based intervention required for a positive outcome, this information does offer an estimate of the number of school-based hours needed by young (preschool-age) children with autism.”
Amount of Direct Intervention: Research Findings
In 2001, at the request of the Office for Special Education Programs (OSEP), the National Research Council (NRC) published Educating Children with Autism, a monograph and recommendations developed by a committee of experts. The committee’s recommendations were made on the basis of empirical findings, information from selected representative programs, and reviews of findings in the general education and developmental literature. The committee noted that “it is well established that children with autism spend much less time in focused and socially directed activity when in unstructured situations than do other children, and it is therefore crucial to specify time engaged in social and focused activity as part of a program for children with autism spectrum disorders.” The committee did not delineate between service levels for children under and over age three, but recommended that:
Based on a set of individualized, specialized objectives and plans that are systematically implemented, educational services should begin as soon as a child is suspected of having an autistic spectrum disorder. Taking into account the needs and strengths of an individual child and family, the child’s schedule and educational environment, in and out of the classroom, should be adapted as needed in order to implement the IEP. Educational services should include a minimum of 25 hours per week, 12 months per year, in which the child is engaged in systematically planned, developmentally appropriate educational activity aimed toward identified objectives. Where this activity takes place and the content of the activity should be determined on an individual basis, depending on the characteristics of both the child and the family. (NRC, 2001).
The NRC Monograph, which represented a consensus among experts in a variety of fields including special education, clinical and developmental psychology, speech and language pathology, psychiatry, and child neurology, supports the following previous findings by academics specializing in the field of autism:
- Provide intensive services to toddlers and preschoolers. The cost of intensive
(one-to-one) services for every two-, three- and four-year-old diagnosed as
having autism or pervasive developmental disorder would undoubtedly be
extremely high. But the current, often feeble attempts at intervention for this
population are unlikely to reduce the even greater cost of maintaining a very
large proportion of autistic individuals as seriously disabled throughout their
lifetimes. It is cost-effective to help as many autistic children as possible
become part of mainstream society early in their lives, and we need intensive
efforts to accomplish this. Not every child diagnosed as having a pervasive
developmental disorder needs 30 or 40 hours a week of formal educational
treatment services for an extended period of time; and some children who begin
receiving intensive services at age two or three will, a year or two later, be able
to learn effectively in small groups and benefit from supported participation in
inclusive settings. (Cohen, 1998) - Moreover, despite widespread recognition that in treatment of autism early is
essential and more is better, the current state-of-the-art treatment in early
intervention for autism is good preschool education. When children with autism
enter treatment before preschool ages, they are usually provided with a diluted
preschool curriculum. There is a void of information on what is most crucial to
teach toddlers with (or at risk for) a diagnosis of autism, or how best to teach
them. This is a critical problem, given the relatively short time frame in which
early intervention must occur. In sum, it is important to know how to best lay a
foundation for the growing number of effective preschool interventions.
(McGee, et al, 1994) - Many parents instinctively try harder and do more and basically add more
stimulation when their child does not respond normally. With autistic children,
however, just adding “more” is not enough. The special difficulties experienced
by autistic children warrant a form of special education unique to their disorder.
Sometimes the most severely impaired children—those for whom even the most
intensive services will not make a critical difference—tend to be offered more
services than children who have fewer initial impairments or who may be more
ready to tolerate intensive work. In fact, children with the mildest disabilities
typically are offered fewer services than more moderately impaired children
because it is felt they may improve eventually on their own. To the extent that
there are any real data on who should get how much service, there is reason to
believe that more intensive interventions for more mildly affected children may
be particularly efficacious. (Seigel, 1996)
Furthermore, the NRC monograph made the following additional recommendations for effective treatment:
• A child must receive sufficient individualized attention on a daily basis, so that
individual objectives can be effectively implemented; individualized attention
should include individual therapies, developmentally appropriate small group
instruction, and direct one-to-one contact with teaching staff.
• Assessment of a child’s progress in meeting objectives should be used on an
ongoing basis to further refine the IEP. Lack of objectively documentable
progress over a three month period should be taken to indicate a need to increase
intensity by lowering student/teacher ratios, increasing programming time,
reformulating curricula, or providing additional training and consultation.
• To the extent that it leads to specified educational goals (e.g., peer interaction
skills, independent participation in regular education), children should receive
specialized instruction in settings in which ongoing interactions occur with
typically developing children. (NRC, 2001).
