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4 Goals for Educational Services There are many different goals for the education of young children with autism. At the root of these goals are societal desires and expecta- tions about the benefits of education for all children, and assumptions about what is important and what is possible to teach children with autis- tic spectrum disorders. Education provides opportunities for the acquisi- tion of knowledge and skills that support personal independence and social responsibility (Kavale and Forness, 1999). For a child with an autis- tic spectrum disorder or any other developmental disability, how inde- pendence and responsible participation in a social world are manifested may include different behaviors from those targeted as goals for more typical children, though often the similarities are greater than the differ- ences. For the purposes of this report, in which we are concerned with children 8 years of age and younger, independence and responsibility are defined in terms of age-appropriate participation in mainstream school and social activities to the extent possible, rather than as vocational or residential independence. There are many behaviors that ordinary children learn without spe- cial teaching, but that children with autism may need to be taught (Klin, 1992). A preschool child with autism may have learned to count back- wards on his own, but may not learn to call to his mother when he sees her at the end of the day without special teaching. A high school student with autism may have excellent computer skills but not be able to decide when she needs to wash her hair. Educational goals for these students, as part of addressing independence and social responsibility, often need to address language, social, and adaptive goals that are not part of standard 40
GOALS FOR EDUCATIONAL SERVICES 41 curricula. Now, both academic and nonacademic goals must be consid- ered against the background of âstandards-based educational reform,â according to which educators will increasingly become accountable for establishing and meeting goals that are challenging for students at all levels of disability, while allowing for individual adaptations for students with significant cognitive disabilities (see National Research Council  for a detailed discussion of the implications of standards-based reform for students with disabilities). As discussed in Chapter 12, most comprehensive early education pro- grams for children with autistic spectrum disorders share similar goals across a range of areas (Handleman and Harris, 2000), though the empha- sis placed by the different programs may differ. These areas include social and cognitive development, verbal and nonverbal communication, adaptive skills, increased competence in motor activities, and ameliora- tion of behavior difficulties. Specific issues within each of these areas are discussed in individual chapters of this report. However, often areas overlap. For example, communication involves both social and represen- tational skills. In addition, priorities change as children develop. Yet challenges in making skills truly useful in terms of spontaneity and generalizability across environments are significant across all areas. INTERVENTIONS AS PATHS TO GOALS Research on the effectiveness of early interventions and on the course of development of autistic spectrum disorders provides some insight into the complexities of the selection of appropriate goals for education in autism. For example, is a therapy addressing a reasonable goal if its primary aim is getting a child with autism to play or to match similar objects? Is it worth the expense and time of the child and parent to drive across town once a week or the disruption for a child to be taken out of class by a therapist in order to meet either of these goals? Generally, outcome research has studied the effectiveness of programs, not the ap- propriateness of various goals. Thus, the question of whether play or matching can be taught is different fromâand can be more easily an- swered thanâthe question of whether or when they should or should not be taught. Educational objectives must be based on specific behaviors targeted for planned interventions. However, one of the questions that arises repeatedly, both on a theoretical and on a clinical basis, is how specific a link has to be between a long-term goal and a behavior targeted for inter- vention. Some targeted behaviors, such as toilet training or acquisition of functional spoken language, provide immediately discernible practical benefits for a child and his or her family. However, in many other cases, both in regular education and specialized early intervention, the links
42 EDUCATING CHILDREN WITH AUTISM between the objectives used to structure what a child is taught and the childâs eventual independent, socially responsible functioning are much less obvious. This is particularly the case for preschool children, for whom play and manipulation of toys (e.g., matching, stacking of blocks) are primary methods of learning and relating to other children. Often, behaviors targeted in education or therapy are not of immedi- ate practical value but are addressed because of presumed links to overall educational goals. The structuring of activities in which a child can suc- ceed and feel successful is an inherent part of special education. Some- times the behavior is one component of a series of actions that comprise an important achievement. Breaking down a series of actions into compo- nents can facilitate learning. Thus, a preschool child may be taught to hold a piece of paper down with one hand while scribbling with another. This action is a first step in a series of tasks designed to help the child draw and eventually write. Other behaviors, or often classes of behaviors, have been described as âpivotal behaviorsâ in the sense that their acquisition allows a child to learn many other skills more efficiently (Koegel et al., 1999; Pierce and Schreibman, 1997). Schreibman and the Koegels and their colleagues have proposed a specific treatment program for children with autism: pivotal response treatment. It includes teaching children to respond to natural reinforcers and multiple cues, as well as other âpivotalâ responses. These are key skills that allow better access to social information. The idea of âpivotal skillsâ to be targeted as goals may also hold for a broad range of behaviors such as imitation (Stone, 1997; Rogers and Pennington, 1991), maintaining proximity to peers (Hanson and Odom, 1999), and learning to delay gratification (understanding âfirst do this, then you get to do thatâ). Longitudinal research has found that early joint attention, symbolic play, and receptive language are predictors of long-term out- come (Sigman et al., 1999). Although the research to date has been prima- rily correlational, one inference has been that if interventions succeed in modifying these key behaviors, more general improvements will occur as well (Kasari, 2000); another explanation is that these behaviors are early indicators of the childâs potential developmental trajectory. Sometimes goals for treatment and education involve attempting to limit and treat the effects of one aspect of autism, with the assumption that such a treatment will allow a child to function more competently in a range of activities. For example, a number of different treatment pro- grams emphasize treating the sensory abnormalities of autism, with the implication that this will facilitate a childâs acquisition of communication or social skills (e.g., auditory integration; sensory integration). For many interventions, supporting these links through research has been difficult. There is little evidence to support identifiable links between general treat- ment of a class of behaviors (e.g., sensory dysfunction) and improve- ments in another class of behaviors (e.g., social skills), especially when the
GOALS FOR EDUCATIONAL SERVICES 43 treatment is carried out in a different context from that in which the targeted behaviors are expected to appear. However, there are somewhat different examples in other areas of education and medicine in which interventions have broad effects on behavior. One example is the effect of vigorous exercise on general be- havior in autism (Kern et al., 1984). In addition, both desensitization (Cook et al., 1993) and targeted exercise in sports medicine and physical therapy often involve working from interventions carried out in one con- text to generalization to more natural circumstances. Yet, in both of these cases, the shift from therapeutic to real-life contexts is planned explicitly to occur within a relatively brief period of time. At this time, there is no scientific evidence of this kind of link between specifically-targeted thera- pies and general improvements in autism outside the targeted areas. Until information about such links becomes available, this lack of findings is relevant to goals, because it suggests that educational objectives should be tied to specific, real-life contexts and behaviors with immediate mean- ing to the child. OUTCOMES Because the range of outcomes for children with autistic spectrum disorders is so broad, the possibility of relatively normal functioning in later childhood and adulthood offers hope to many parents of young children. Although recent literature has conveyed more modest claims, the possibility of permanent ârecoveryâ from autism, in the sense of even- tual attainment of language, social and cognitive skills at, or close to, age level, has been raised in association with a number of educational and treatment programs (see Prizant and Rubin, 1999). Natural history stud- ies have revealed that there are a small number of children who have symptoms of autism in early preschool years who do not have these symp- toms in any obvious form in later years (Szatmari et al., 1989). Whether these improvements reflect developmental trajectories of very mildly af- fected children or changes in these trajectories (or more rapid movement along a trajectory) in response to treatment (Lovaas, 1987) is not known. However, as with other developmental disabilities, the core deficits in autism have generally been found to persist in some degree in most persons with autistic spectrum diagnoses. There is no research base ex- plaining how ârecoveryâ might come about or which behaviors might mediate general change in diagnosis or cognitive level. Although there is evidence that interventions lead to improvements and that some children shift specific diagnoses within the spectrum and change in severity of cognitive delay in the preschool years, there is not a simple, direct rela- tionship between any particular current intervention and ârecoveryâ from autism. Because there is always room for hope, recovery will often be a goal for many children, but in terms of planning services and programs,
44 EDUCATING CHILDREN WITH AUTISM educational objectives must describe specific behaviors to be acquired or changed. Research on outcomes (or whether goals of independence and re- sponsibility have been attained) can be characterized by whether the goal of an intervention is broadly defined (e.g., âbest outcomeâ) or more nar- rowly defined (e.g., increasing vocabulary, increasing peer-directed so- cial behavior); whether the study design involves reporting results in terms of individual or group changes; and whether goals are short term (i.e., to be achieved in a few weeks or months) or long term (i.e., often several years). A large body of single-subject research has demonstrated that many children make substantial progress in response to specific in- tervention techniques in relatively short time periods (e.g., several months). These gains occur in many specific areas, including social skills, language acquisition, nonverbal communication, and reductions of chal- lenging behaviors. Often the most rapid gains involve increasing the frequency of a behavior already in the childâs repertoire, but not used as broadly as possible (e.g., increasing use of words) (Watson et al., 1989). In single-subject reports, changes in some form are almost always docu- mented within weeks, if not days, after the intervention has begun. Stud- ies over longer periods of time have documented that joint attention, early language skills, and imitation are core deficits that are the hallmarks of the disorder, and are predictive of longer-term outcome in language, adaptive behaviors, and academic skills. However, a causal relationship between improvements in these behaviors as a result of treatment and outcomes in other areas has not yet been demonstrated. Many treatment studies report postintervention placement as an out- come measure. Successful participation in regular education classrooms is an important goal for some children with autism. However, its useful- ness as an outcome measure is limited because placement may be related to many variables other than the characteristics of a child (such as pre- vailing trends in inclusion, availability of other services, and parentsâ preferences). The most commonly reported outcome measure in group treatment studies of children with autism have been IQ scores. Studies have re- ported substantial changes in IQ scores in a surprisingly large number of children in intervention studies and in longitudinal studies in which chil- dren received nonspecific interventions. These are discussed in more detail in Chapter 7. However, even in the treatment studies that have shown the largest gains, childrenâs outcomes have been variable, with some children making great progress and others showing very small gains. Overall, while much evidence exists that education and treatment can help children attain short-term goals in targeted areas, gaps remain in addressing larger questions of the relationship between particular tech- niques and both general and specific changes.
II Characteristics of Effective Interventions