The Big 3 Therapeutic Approaches to Autism

The main therapeutic approaches with autism today are Applied Behavior Analysis (ABA); Developmental, Individual Difference, Relationship-Based Therapy (DIR, also known as “Floortime”); and Relationship Developmental Intervention (RDI), the one we use for Brian.

Ivar Lovaas developed the ABA treatment, the most researched of the ASD therapies, based on the principles of psychologist B. F. Skinner’s operant conditioning. Children are helped to learn by breaking goals down into small steps and chaining them together—a process called Discrete Trial Teaching (DTT). For example, the process of putting on socks and shoes is broken down into its component steps and practiced until mastered. It’s an extremely labor-intensive form of one-on-one individually oriented training, done by therapists or paraprofessionals, who take extensive notes to direct future activities. The original model required up to 40 hours a week of therapy with professionals and paraprofessionals, but today, families generally do fewer hours, perhaps because the costs are prohibitive.

Like everything else having to do with autism, ABA raises controversies, despite its relatively stronger research base. I remember being told to avoid ABA because it made kids “robotic and less juicy.” Some say that ABA is the treatment of choice for low-functioning children, because it helps them learn basic skills, like sitting in a chair and following simple directions, but that it doesn’t work as well with high-functioning children. In addition, the labor, time, and money involved can be prohibitive—not to mention the disruption of having providers in and out of the home all week.

The second major approach is Floortime, developed by child psychiatrist Stanley Greenspan. A “child-led” approach , it helps children with autism grow by taking their interests, which are often solitary ones, and expanding and deepening them. The therapist or parent helps the child become emotionally regulated and then gently intrudes on his/her solo play, guiding the child in mastering relational, emotional, and intellectual skills. For example, a child may be repetitively pushing a toy car back and forth on the carpet. Mom approaches with her toy car, gets down on the carpet, and pushes her car in parallel with his. If he doesn’t become upset, she ups the ante by adding sound effects, and soon begins to bump into his car.

Floortime, too, requires huge amounts of time. One friend was told by her son’s therapist that to help him, she should do at least 10 Floortime play sessions with him every day, lasting 20 minutes each, or more than 3 hours a day—an almost impossible request that made her feel both overburdened and inadequate. There’s ongoing tension between the Floortime folks and the ABA folks, which can be confusing for parents who are trying to make a choice of where to invest their treatment time and money.

The new kid on the block is RDI therapy, which is described in greater detail in the body of the article.