TORONTO—Remember when nobody thought that the outlook for autistic children could ever be positive, that these children were always doomed to remain as they were with no hope of improving their intelligence, functioning independently, or going to mainstream schools? That outlook may be changing.

Preliminary findings from the Ohio Autism Recovery Project confirmed that children diagnosed with autism and mental retardation can improve and sometimes even achieve normal intelligence when they receive early intensive behavioral intervention (EIBI). James A. Mulick, PhD, shared the findings at the Annual Convention of the American Psychological Association.

Before they received EIBI, all eight of the children in the study had an IQ below 51 and were considered moderately mentally retarded. After one to four years of EIBI carried out by several different agencies, they all achieved an IQ of 70 or higher; one child’s IQ reached 114. Almost all of the children became adaptable enough to be considered by their school systems to be ready for mainstream schooling.

“However, EIBI only seems to work well in children with autism who are otherwise healthy, like those in our study,” Dr. Mulick told NEUROPSYCHIATRY REVIEWS. “We do not really see any lasting change in those with other syndromes such as CNS malformations or uncontrollable seizures.” Also, among children with autism who do improve, there can still be residual symptoms such as irritability and problems with language, added Dr. Mulick, Professor of Pediatrics and Psychology at Ohio State University in Columbus.

“YOU BECOME WHAT YOU DO”

The EIBI method was first developed about 30 years ago by O. Ivar Lovaas, PhD, Professor Emeritus of Behavioral Neuroscience at the University of California, Los Angeles, who reported in 1987 that 47% of the 19 children with autism who took part in an EIBI program attained normal intellectual and educational functioning. Although that study was highly criticized for selection bias and other limitations, it raised awareness of EIBI’s potential benefit.

“You become what you do” is the mantra of Dr. Mulick’s Comprehensive Autism Center at Children’s Hospital in Columbus. Therefore, the autistic children participating in the Intensive Behavioral Intervention (IBI) Clinic arm of the program undergo 40 hours a week of behavioral therapy for three years. This should ideally begin as early in life as possible to prevent the child’s nervous system from becoming increasingly accustomed to supporting autistic behaviors, Dr. Mulick said.

The children that he described ranged in age from 4 to 8. To be included in the study, they had to have been reliably diagnosed with autism and mental retardation before receiving any EIBI. Notably, there was no control group. That, explained Dr. Mulick, is because EIBI has usually produced such promising results that it would be unethical not to offer it to an autistic child for extended periods.

In the IBI Clinic at Columbus Children’s Hospital Close to Home Center in Westerville, Ohio, which is directed by Jacqueline Wynn, PhD, and is based on Dr. Lovaas’ model, the children’s first task is to learn how to imitate by mirroring arm motions and other actions. The complexity of the program grows over time, with the children gradually learning how to match identical objects, followed by similar objects, and then categories or attributes of objects.

“Once they can imitate and match, you can teach them how to talk,” Dr. Mulick said. One method of teaching language skills involved showing the children an object, asking them what it was, and then prompting them with the correct response until they can answer correctly before the prompt. Such “errorless instruction” prevents the autistic child from practicing errors, and eventually, prompting becomes unnecessary.

“Something very magical happens after many months of adding words one at a time,” related Dr. Mulick. “When the kids are going to show an IQ boost, I am convinced that they begin to use their words to learn new words outside of sessions. To me, that is a sign that something has clicked.”

Rewarding the children with enthusiastic compliments when they do well facilitates success. Not allowing them to withdraw socially, as many autistic children are wont to do, is also important and, fortunately, often quite simple. “A lot of these children are little kids, so it is not that difficult to, for example, hold them on your lap like any parent does with a small child,” explained Dr. Mulick.

MORE THAN A HIGHER IQ

In addition to the IQ increases that were observed, all of the children in the study improved their nonverbal cognitive abilities (eg, solving a puzzle or unlocking a door) to borderline or normal, and they all developed academic ability adequate for mainstream schooling. Seven children showed significant improvement in adaptive behaviors such as dressing and hand washing, which are important for all children.

After their variable courses of EIBI, only one of the children displayed symptoms so severe as to be classifiable as autistic. And, only one child was still clearly having the emotional and behavioral problems that are common in autism. Not surprisingly, however, four children continued to have problems with their language skills. “Language is one of the most impaired areas in autism,” Dr. Mulick said.

PRACTICE MAKES PERFECT

Dr. Mulick estimated that the percentage of children who respond maximally to EIBI is probably nowhere near the 47% that Dr. Lovaas reported. “That finding was a fluke and perhaps a product of biased subject selection, as many have suggested,” he commented. “But I do believe that EIBI has a benefit related to the programming of the nervous system through intensive practice.”

For the children in Dr. Mulick’s study, only long-term follow-up will answer the question of whether EIBI can produce IQ and other improvements that last beyond childhood. Meanwhile, Dr. Mulick and his colleagues are beginning to assess the effect of EIBI in other syndromes associated with mental retardation.

—Timothy Begany

Suggested Reading
Jacobson JW, Mulick JA. System and cost research issues in treatments for people with autistic disorders. J Autism Dev Disord. 2000;30:585-593.
Lovaas OI. Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consult Clin Psychol. 1987;55:3-9.
McEachin JJ, Smith T, Lovaas OI. Long-term outcome for children with autism who received early intensive behavioral treatment. Am J Ment Retard. 1993;97:359-372.
Mulick JA, Butter EM. Educational advocacy for children with autism. Behavioral Interventions. 2002;17:54-74.
Smith T, Eikeseth S, Klevstrand M, Lovaas OI. Intensive behavioral treatment for preschoolers with severe mental retardation and pervasive developmental disorder. Am J Ment Retard. 1997;102:238-249.

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