Autism spectrum disorder is characterized by deficits in social communication and restricted, repetitive and/or sensory behaviours or interests. The severity levels should be specified.
In the 1970s, only 1.5% of the children with ASD achieved normal functioning. About 35% showed good adjustment but required some degree of supervision. The majority (i.e. 60%) remained severely handicapped. About 50% remained non-verbal throughout their lives. Currently, this is less than 10%. However, ASD does not need to be a life-long disabling condition. About 25% of the children can lose the diagnosis after treatment and most children can achieve positive outcomes with treatment. Children who lose the diagnosis will become similar to typically developing children.
There are several criteria for when an intervention is successful:
However, when an intervention is truly successful depends on the goals of the parents and the child. The intervention should aim to improve on these goals and should thus be matched to their goals.
Lovaas’ discrete trial training (DTT) demonstrated that behaviour modification treatment could lead to positive outcomes for children with ASD. This training makes use of operant techniques and breaks skills into small component and teaches the child one component at a time. According to Lovaas, children with ASD are unsuccessful in learning skills from the natural environment and the environment should thus include potent reinforcers and should be simplified. This means that every small step is rewarded. Though the training seems effective, there is a lack of generalization of learned skills (1), it leads to avoidance behaviour (2), there is a lack of spontaneity (3) and there is an overdependence on prompts (4). This could be because the treatment is very therapist-directed.
Applied behavioural analysis refers to the process of systematically applying interventions based upon learning theory principles to improve socially significant behaviours to a meaningful degree. It aims to change behaviour by investigating what is reinforcing the behaviour and it is the core of all interventions for ASD.
The core of all interventions for ASD is applied behavioural analysis. This refers to systematically applying interventions based on learning theory principles to improve socially significant behaviours to a meaningful degree. This approach aims to change behaviour by investigating what is reinforcing the behaviour:
ABA can focus on social skills (1), communication (2), play (3), behaviour (4), adaptive skills (5), motor skills (6) and cognitive skills (7), meaning that the focus of ABA in children with ASD can be very heterogeneous. These skills often develop naturally in typically developing children.
ABA attempts to understand and alter the environment to change behaviour using the ABC contingency:
The aim is to increase desirable and decrease undesirable behaviours using this contingency. Reinforcement increases the future likelihood of behaviour. This can be positive (i.e. adding an environmental stimulus) or negative (i.e. removing an environmental stimulus). Punishment decreases the future likelihood of behaviour. This can also be positive or negative. Extinction refers to removing reinforcement of undesirable behaviour.
Treatments for children with ASD should have several characteristics:
Naturalistic developmental behavioural interventions (NDBIs) refer to empirically supported autism interventions that represent the merging of applied behavioural and developmental sciences. These intervention employ a naturalistic and interactive social context and involve child-directed teaching strategies). It has several characteristics (i.e. common elements):
NDBIs have several benefits:
NDBIs attempt to provide the child with an infrastructure to support efficient and effective learning. These interventions aim to establish adult-child engagement activities that transform into motivating play routines or familiar daily life routines as learning is improved when it is embedded in activities that contain emotionally meaningful interactions.
The pivotal response treatment (PRT) is an example of a NDBI. The key assumption of PRT is trying to teach pivotal skills to children. It states that when learning occurs with these skills, natural learning will occur in other areas. Motivation to respond to social and environmental stimuli is essential for typical development but children with ASD may fail to understand the interconnection between their behaviour and the consequences from their environment as a result of repeated failures and non-contingent assistance and reinforcement from adults. This can lead to learned helplessness. PRT aims to decrease learned helplessness by enhancing the relationship between children’s responses and reinforcement.
This can enhance motivation and this may lead to a positive feedback loop where more learning opportunities are provided, which may generate the social-environmental conditions for the development of more complex behaviours.
It focuses on several pivotal skills:
Children with ASD are often unmotivated to socialize but are motivated to engage with non-social aspects of their environment. The salient characteristics of non-social interests may be identified and embedded within a reciprocal social activity. This can enhance motivation to socialize. Incorporating restricted activities in mutually-reinforcing social activities can lead to intrinsic motivation for social play.
Parents should also deliver PRT to provide consistency for the child. There is a greater treatment effectiveness when it is delivered by parents compared to clinicians. They receive direct feedback from the therapist while working with the child on the following:
The Early Start Denver Model (ESDM) is another example of a NDBI and is based on ABA, PRT and social motivation hypothesis. The goal is to accelerate children’s developmental rates in cognitive, social-emotional, language, and adaptive domains and to reduce the disabling effect of ASD symptoms. The focus of the treatment is on children between the ages of 12 and 60 months. The treatment takes place within naturalistic settings.
There are several components:
It aims to utilize imitation to teach skills in other domains. ESDM enhances the reward value of social interaction. Each treatment objective is broken down into several teaching steps based on a task analysis of the skill (i.e. the child’s current baseline level and ending with a fully mastered and generalized skill).
The social motivation hypothesis states that children with ASD have an impaired sensitivity to reward value of social stimuli. This leads them to pay reduced attention to social stimuli. The reduced attention, in turn, leads to fewer learning opportunities.
There are different versions of ESDM:
People participating in ESDM maintained gains in early intervention for 2 years in intellectual ability (1), adaptive behaviour (2), symptom severity (3) and challenging behaviour (4). ESDM is associated with improvements in brain activity (e.g. enhanced brain activity in regions related to social processing; greater cortical activation while viewing faces). There are three potential neural mechanisms of ESDM:
The recommendation is that children should receive 20 hours per week for two years of ESDM. The treatment should thus be very intensive. However, there are several barriers to intensive interventions:
The parent-child education programme is a less intensive treatment based on ESDM. In this treatment, parents master the strategies and this leads to sustained change and growth in social communication behaviours. This allows the treatments to be less intensive. The parents learn to focus on the child and the interaction more. There are mixed findings for the efficacy of 12-week online parent training based on ESDM.
Single-case studies demonstrate the effective components of manualized treatments but using a different order of delivering the components and using frequent assessment. Important components (i.e. techniques) include stepping into the attentional spotlight of the child (1), talking to the infant (2) and imitation (3).
An intervention is more useful when it starts at a younger age:
The reduces effectiveness with age may be due to reduced brain plasticity and this suggests the existence of a critical period. ASD symptoms (e.g. aggression; tantrums; self-injury) often have a communicative function. As early intervention improves verbalization, these secondary symptoms may reduce. Similarly, comorbid symptoms are often related to difficulties with socialization and this is improved with early intervention.
Early intervention could also provide parents with tools to address symptoms and this could lead to more self-confidence and a feeling of empowerment, which is useful as a child with a disability leads to a lot of stress. These tools could improve parenting.
ESDM leads to positive results when it is administered to infants. One-on-one interventions delivered at home are very effective for children with autism due to the generalization of skills. However, starting treatment early is difficult as screening for ASD in very young children is often very difficult for several reasons:
There is a different treatment goal and approach for different target symptoms in ASD:
Symptom | Theme | Goal | Procedure |
Visual fixation on symptoms. | Joining into toy play. | Facilitate attention shifting from object to parent (1) , parallel play (2) and sharing of emotion regarding the object (3). | Follow infant interest to an object and develop a social turn-taking game. |
Abnormal repetitive behaviours | Encouraging flexible and varied actions and play. | Increase the number and maturity of schemas a child uses. | Follow infant-interest while developing age-appropriate sensory motor schemas for object play and shape motor movements into communicative gestures using a prompted hierarchy. |
Lack of intentional communicative acts and lack of coordination of gaze, affect, and voice in reciprocal, turn-taking interactions. | Increasing engagement and interaction. | Elicit communicative gestures and vocalizations (1) and integrated communicative behaviours (2) for varied pragmatic intents. | Offer and follow the child into preferred activities and dyadic and triadic joint activities. Increase and shape these behaviours via prompting, shaping, fading and reinforcement. |
Lack of age-appropriate phonemic development. | Development of foundations of speech. | Increase the frequency of child vocalizations (1) and shape specific consonants and vowels (2). | Use imitation and other interaction strategies and reinforcement, shaping and prompting. |
Decreasing gaze, social interest and engagement. | Maximizing social attention. | Maximize gaze and increase infant pleasure and engagement in social interaction. | Position self and child for maximal face-to-face orientation and provide object and social games that follow infant preferences. |
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Youth Intervention: Theory, Research, and Practice – Lecture 0 (UNIVERSITY OF AMSTERDAM) 
There are several major principles of youth interventions:
Children not referring themselves leads to problems with client motivation and problem awareness. There are three levels of youth intervention:
Treatment refers to targeting youth with symptoms at (sub)clinical level or those with a diagnosis. Heterogeneity in complaints exist because of three reasons:
The question is always where one should intervene when a child presents with complaints. Efficacy refers to whether an intervention works in a controlled, laboratory setting. Effectiveness refers to whether an intervention works in clinical practice. An evidence-based intervention refers to an intervention where there is at least some evidence regarding the efficacy and effectiveness. However, there is no clear guideline for when something is evidence-based as it is a continuum. Most include at least two studies with the following:
There are several ways in which a treatment can be considered well-established:
Or alternatively, when a large series of single-case designs have been used, it must demonstrate efficacy with:
When an experiment is used, it must be conducted with treatment manuals (1), characteristics of the sample must be specified (2) and the effects must be demonstrated by at least two different teams (3).
An intervention is probably efficacious when there are at least two experiments that show that the treatment is superior to the waiting list control-group or when the treatment is well-established but has not been investigated by at least two teams. Alternatively, a treatment is probably efficacious when a small series of single-case design experiments meet well-established treatment criteria. An intervention is an experimental treatment when treatment has not been tested in trials meeting criteria for methodology.
Evidence-based practice refers to using evidence-based interventions and using available knowledge about the effectiveness and efficiency of a method in carrying out an
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 1 (UNIVERSITY OF AMSTERDAM) Children should have at least five symptoms for a period of two weeks including either the first or the second one to be diagnosed with major depressive disorder:
There are also some secondary symptoms:
Physical complaints (e.g. headaches; stomach aches) are more common in children. Substance use (e.g. alcohol; drugs) is more common in adolescence. The prevalence of major depressive disorder is 2.8% in school-age children (i.e. 6-12 years) and 5-6% in adolescents (i.e. 13-18 years). However, compared to adults, children and adolescents are still underdiagnosed and undertreated.
The general guideline for mild to moderate depression is psychosocial treatment. For severe depression, the guideline is a combination of psychosocial treatments and medication. However, one should be cautious with using medication with children and adolescents as there is an increased suicide risk with medication use. This may be because the medication increases impulsiveness. It should always be used in the context of extensive case conceptualization and in consultancy with a psychiatrist.
Beck’s cognitive theory of depression states that depression is the result of negative cognitions. There are automatic negative interpretations of ambiguous situation and cognitive errors (e.g. “bad things happen because of me”). This leads to negative schemes (e.g. “I am unlovable) which leads to depression. The negative beliefs are activated when faced with stressful circumstances and this interferes with coping and positive mood. There is black and white thinking, selective observation, overgeneralization and personalization of negative events (i.e. personal attribution). Depressogenic thinking is resistant to disconfirmation, partially due to the enduring styles of information processing that promote belief maintenance (e.g. focus on negative information).
The cognitive vulnerability model states that individuals at risk for depression selectively focus on and have better memory recall for negative rather than positive stimuli. A behavioural approach to depression holds that depression results from low levels of positive reinforcement and high levels of punishment and aversive control. This leads people to withdraw from negative interactions and avoid situations that may produce low positive reinforcement which, eventually, leads to a depressive cycle.
Theory is necessary because explaining the rationale behind a treatment makes it more understandable for a client and improves treatment adherence. The client needs to view the treatment as useful and needs to understand why
Cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) are two effective treatments and are
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 2 (UNIVERSITY OF AMSTERDAM) There are three learning paths to fear:
There are three intervention techniques for anxiety:
The information processing theory holds that attention, interpretation and memory biases will lead to problematic cognitions. This means that an ambiguous situation (e.g. “seeing children laugh”) could be interpreted negatively (e.g. “they are laughing at me”) and this could lead to a memory bias (e.g. “I only remember people laughing at me when I wore this t-shirt”).
All treatment protocols for anxiety treatment starts psychotherapy. Next, the child is prepared for exposure by doing cognitive therapy or relaxation technique. Afterwards, there is conduct of modelling and exposure.
Cognitive-behavioural therapy is the most evidence-based prevention and treatment method for anxiety disorders. The recovery rate for anxiety disorders after using CBT is approximately 60%.
There are several principles (i.e. steps) of cognitive therapy for anxiety:
The goal of CBT is cognitive restructuring. Children also receive homework in CBT. The situation-thought feeling (the five G’s) is used to give insight for the client and is a tool for the therapist regarding treatment course:
The client has to identify all and elaborate on them. Detecting the negative thoughts can be done by using questionnaires or by using cartoons. People often find it difficult to formulate helping thoughts. Therapists can help them by provide the client with this or help them formulate it (e.g. give examples).
The presence of social anxiety disorder at pre-treatment leads to slower rate of change and poorer diagnostic outcomes when using CBT. This may be as group settings are more aversive for them. They may also show behavioural inhibition from infancy, making them more resistant to change. The therapeutic relationship may also be more problematic due to their SAD. Exposure may have opposite effects as social situations are more ambiguous and more difficult to interpret. This makes it difficult to see whether one’s initial interpretation was false.
Children with SAD may thus need a longer treatment programme and a more tailored programme that helps them disconfirm their negative social expectations (e.g. equip children with social skills prior to exposure). One way in which this can be
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 3 (UNIVERSITY OF AMSTERDAM) Autism spectrum disorder is characterized by deficits in social communication and restricted, repetitive and/or sensory behaviours or interests. The severity levels should be specified.
In the 1970s, only 1.5% of the children with ASD achieved normal functioning. About 35% showed good adjustment but required some degree of supervision. The majority (i.e. 60%) remained severely handicapped. About 50% remained non-verbal throughout their lives. Currently, this is less than 10%. However, ASD does not need to be a life-long disabling condition. About 25% of the children can lose the diagnosis after treatment and most children can achieve positive outcomes with treatment. Children who lose the diagnosis will become similar to typically developing children.
There are several criteria for when an intervention is successful:
However, when an intervention is truly successful depends on the goals of the parents and the child. The intervention should aim to improve on these goals and should thus be matched to their goals.
Lovaas’ discrete trial training (DTT) demonstrated that behaviour modification treatment could lead to positive outcomes for children with ASD. This training makes use of operant techniques and breaks skills into small component and teaches the child one component at a time. According to Lovaas, children with ASD are unsuccessful in learning skills from the natural environment and the environment should thus include potent reinforcers and should be simplified. This means that every small step is rewarded. Though the training seems effective, there is a lack of generalization of learned skills (1), it leads to avoidance behaviour (2), there is a lack of spontaneity (3) and there is an overdependence on prompts (4). This could be because the treatment is very therapist-directed.
Applied behavioural analysis refers to the process of systematically applying interventions based upon learning theory principles to improve socially significant behaviours to a meaningful degree. It aims to change behaviour by investigating what is reinforcing the behaviour and it is the core of all interventions for ASD.
The core of all interventions for ASD is applied behavioural analysis. This refers to systematically applying interventions based on learning theory principles to improve socially significant behaviours to a meaningful degree. This approach aims to change behaviour by investigating what is reinforcing the behaviour:
ABA can focus on social skills (1), communication (2), play (3), behaviour (4), adaptive skills (5), motor skills (6) and cognitive skills (7), meaning that the focus of ABA in children with ASD can be very heterogeneous. These skills often develop naturally in typically developing children.
ABA attempts to understand and alter the environment to change behaviour using
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 4 (UNIVERSITY OF AMSTERDAM) There are several guidelines for treating children with ADHD:
Behavioural intervention cannot be supported as a front-line treatment for core ADHD symptoms. This is especially the case in studies where the outcomes are blinded. However, parenting practices and conduct problems improve after behavioural interventions and this is often the main reason for referral, meaning that behavioural interventions serve their goal. Improving parents’ behaviour towards their children may improve child behaviour and improve the quality of the parent-child relationship.
Children who receive behavioural consultation are less likely to receive medication later that year. If they do receive medication, the dosages are lower compared to children who did not receive behavioural consultation. Using a low-intensity behavioural intervention as a first-line treatment reduces or eliminates the need for medication in children with ADHD.
There are several reasons why it is important to reduce the need for medication:
Adding medication secondary to initial behavioural treatment leads to better outcomes on primary outcomes than the other way around. Parents who began treatment with behavioural parent training had better attendance than those assigned to receive training after medication. The cost of starting with a low-intensity behavioural intervention is also lower. It is thus important to start with behavioural intervention.
Behaviour modification is teaches skills to parents, teachers and children to overcome some of the key functional impairments associated with ADHD. Effective treatments need to focus on peer relationships (1), parenting (2) and academic functioning (3). Combining recreational activities with educational activities increases children’s attendance.
Behavioural parent/teacher training is a mediation therapy. This means that the therapist trains the parent or teacher and this person then uses their newly learned skills on the child. This is done because interventions directly involving the child often have little effect due to self-regulation problems of children with ADHD. Using both parents may increase the consistency of the implementation of strategies and shared understanding of ADHD which may lead to better outcomes. However, the evidence for this is limited.
Barriers to parent training include situational factors (1), psychological factors (2), lack of awareness of programmes (3), unavailability of programmes (4) and issues with poor interagency collaboration (5). There are several moderators of treatment effect:
Youth Intervention: Theory, Research, and Practice – Lecture 5 (UNIVERSITY OF AMSTERDAM) When treating criminals in the past, severe punishments were used. Later, phrenology was used to diagnose people and electro convulsion therapy was used to treat people with a criminal history.
Durkheim stated that every society gets the criminality that it deserves. The cost of incarceration is higher than that of rehabilitation. Martinez stated that people who commit crimes should be locked up. According to him, it is impossible to treat criminals. Early (humane) treatment for criminals consisted of CBT. It was focused on treating the symptoms and did not include the families.
Static risk factors refer to risk factors that cannot be changed and are fixed. Dynamic risk factors refer to risk factors that are malleable. The interaction between risk and protective factors and the interaction between the individual and the environment is essential for criminality.
The age crime curve refers to criminal activity increasing during adolescence and peaking during late adolescence. This could be due to the maturity gap (i.e. a well-developed affective brain circuitry and a less developed prefrontal cortex control centre in the brain, combined with adult responsibilities).
The outcome of therapy is influenced by several factors:
There is a lot of innovation in the therapy of juvenile delinquents. This includes real-time biofeedback treatment and virtual reality treatment. Group therapy consists of treatment of aggression (1), improving social skills (2), making moral choices (3) and help meetings (4). However, it can lead to a lot of peer contagion, making it typically ineffective.
There are different forms of systemic treatments:
There are three stages of systemic treatments:
Building a therapeutic alliance takes time and it is important to be patient as the patients are typically not motivated to change. The alliance between the patient and all important people (e.g. parents; therapists; friends) and the alliance between these people is essential.
Understanding the common elements of treatments could render them more effective. Many treatments have common elements, yet a unique focus which allows for personalization. Knowledge of treatment mechanisms and identification of potent treatment techniques can support enhanced precision in matching systemic treatment to the needs of adolescents and their families.
There are six mechanisms (i.e. common elements) of systemic treatment:
Youth Intervention: Theory, Research, and Practice – Lecture 6 (UNIVERSITY OF AMSTERDAM) Traditionally, a specific learning disability (SLD) referred to a discrepancy of one to two standard deviations between intellectual functioning and academic functioning. However, the amount of discrepancy was arbitrary (1), older children were favoured (2), higher IQs were favoured (3) and it was failure-based (4). Currently, the definition holds that achievement in key academic areas is substantially below the age norm and in excess of sensory deficits, linguistic processes, attention and memory. The prevalence is 2 to 10%.
Response to intervention (RTI) refers to a tiered system in which a failure to respond to an intervention is the criterium for identification of specific learning disabilities. This indicates the need for more specific and intensive intervention. First, there is screening for risk (e.g. simple tests of basic pre-reading skills) and assessment of family history of reading and language difficulties. After this, there are several tiers:
In the Netherlands, there are three different but similar tiers:
A child moves to the next tier if the progress in a tier is inadequate. The three-tier model is the most common model of RTI and is defined by three sequentially ordered intervention strategies. It aims at early identification of at-risk children.
All tiers depend on continuous monitoring of student progress as this determines the eligibility for a given tier. It thus does not look at an IQ-achievement discrepancy. A diagnostic classification depends on the outcomes of different interventions. The majority of children who identified as at-risk at first scored average after one or two semesters of tutoring (i.e. tier 1). This means that most struggling readers can become average-level readers if they are provided with effective intervention.
Almost all children identified as at-risk for long-term reading difficulties in first grade had the same characteristics:
This means that not dyslexia but poor education was
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 7 (UNIVERSITY OF AMSTERDAM)For a personality disorder to be diagnosed in adolescence, the problems have to be present for a year. There are four main areas of deficit:
There are several symptoms of borderline personality disorder (BPD):
It is essential to assess how severe the symptoms are. The guidelines for personality disorder are treatment using DBT (1), mentalization-based treatment (2) or schema-focused therapy (3). In dialectical behaviour therapy (DBT) there is a constant search for balance between the different theories on which it is based:
It is an efficacious treatment for BPD as well as for depressed older adults and individuals with eating disorders. It focuses on teaching skills for enhancing emotion regulation (1), distress tolerance (2) and building a life worth living (3).
Dialectical strategies include balancing irreverent and reciprocal communication, as well as acceptance-based and change-based interventions. Reciprocity includes listening and understanding (1), self-disclosure (2) and a sincere warmth (3). Irreverent includes obtaining attention for a subject (1), shifting the affective response (2) and introducing a new perspective (3). Dialectical strategies may be effective through enhanced orienting responses (e.g. by remaining attentive to what is happening, cognitive processing, attention and learning may be influenced) and in vivo learning and modelling.
There are several assumptions of DBT:
Youth Intervention: Theory, Research, and Practice – Lecture 8 (UNIVERSITY OF AMSTERDAM)Trauma refers to a normal response to an abnormal event. About 14% of the children exposed to a trauma develop PTSD. The probability of developing PTSD increase the longer and more severe the traumatic events are.
PTSD includes several symptoms:
The symptoms need to last for at least a month. For late-onset PTSD, the symptoms need to have an onset of 6 months after the traumatic event. The intrusion symptoms in children are represented in pretend play (e.g. playing the traumatic experience). Regressive behaviour (e.g. going back a developmental step) is common in children with PTSD.
There are several risk factors to develop PTSD:
There are also several secondary sources of stress as a risk factor:
There are also several risk factors in children:
Ehler and Clarke’s cognitive model of PTSD states that persistent PTSD only occurs if individuals process the traumatic event and/or consequences in a way which produces a sense of serious, current threat. People with persistent PTSD are unable to see the trauma as a time-limited event that does not have global implications for their future. There are two key processes that lead to this sense of threat:
The perception of current threat is accompanied by intrusions and other re-experiencing symptoms when activated. This motivates a series of behavioural and cognitive responses that are intended to reduce perceived threat and distress in the short-term but prevent cognitive change. This maintains the disorder.
The emotional processing theory states that posttraumatic symptoms reflect the development of a problematic fear structure comprising many stimuli, responses and meaning representations. There are maladaptive responses when this is triggered.
The social cognitive theory focuses on the impact of trauma on pre-existing or developing beliefs about one’s self, others and the world. According to this theory, trauma-related feelings
.....read more
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