Treatment and education of autistic and related communication handicapped children

Treatment and education of autistic and related communication handicapped children (TEACCH) is a service, training, and research program for individuals of all ages and skill levels with autism spectrum disorders. The TEACCH approach was developed at the University of North Carolina, originating in a child research project begun in 1964 by Dr Eric Schopler and Dr Robert Reichler. The results of this pilot study indicated that the children involved made good progress, and consequently state finance supported the formation of Division TEACCH. Founded in 1966 by Eric Schopler at the University of North Carolina at Chapel Hill, TEACCH provides training and services geared to helping autistic children and their families cope with the condition. With over 40 years of experience of working with autistic people, TEACCH methodology continues to evolve, refining its approach. The TEACCH philosophy recognises autism as a lifelong condition and does not aim to cure but to respond to autism as a culture. Core tenets of the TEACCH philosophy include an understanding of the effects of autism on individuals; use of assessment to assist programme design around individual strengths, skills, interests and needs; enabling the individual to be as independent as possible; working in collaboration with parents and families

The emphasis on individualization means that TEACCH does not distinguish between people with very high skill levels and those with learning disabilities. Strategies used are designed to address the difficulties faced by all people with autism, and be adaptable to whatever style and degree of support is required TEACCH methodology is rooted in behavior therapy, more recently combining cognitive elements, guided by theories suggesting that behavior typical of people with autism results from underlying problems in perception and understanding. The strategies put forward by TEACCH do not work on the behavior directly, but on its underlying reasons, such as lack of understanding of what the person is expected to do or what will happen to them next, and sensory under- or over-stimulation. By addressing communication deficits, the person will be supported to express their needs and feelings by means other than challenging behavior.

Working from the premise that people with autism are predominantly visual learners, intervention strategies are based around physical and visual structure, schedules, work systems and task organisation. Individualised systems aim to address difficulties with communication, organisation, generalisation, concepts, sensory processing, change and relating to others. Whereas some interventions focus on addressing areas of weakness, the TEACCH approach works with existing strengths and emerging skill areas and employs alternative and augmentative communication techniques in a supportive environment.

Most of the literature is of North American origin. The adoption of the TEACCH approach elsewhere has been later to begin. In 1993, Jones et al. stated that there was insufficient use of the TEACCH approach in the UK to include it in their study of interventions. However, five years later Jordan, Jones and Murray describe TEACCH as the most common intervention used with children with autism in the UK.

TEACCH runs conferences in North Carolina and organizes programs throughout the USA and in the UK.

Research
TEACCH has been running for several decades and a range of studies indicates that it is an effective intervention for autism, although the studies did not meet all the criteria to qualify TEACCH unreservedly as evidence based practice.

Concerns have been raised about the influence on intervention outcomes from staff member skills and experience.

Structured teaching is an important priority because of the TEACCH research and experience that structure fits the "culture of autism" more effectively than any other techniques we have observed. Organising the physical environment, developing schedules and work systems, making expectations clear and explicit, and using visual materials have been effective ways of developing skills and allowing people with autism to use these skills independently of direct adult prompting and cueing. These priorities are especially important for students with autism who are frequently held back by their inability to work independently in a variety of situations. Structured teaching says nothing about where people with autism should be educated; this is a decision based on the skills and needs of each individual student. Some can work effectively and benefit from regular educational programs, while others will need special classrooms for part or all of the day where the physical environment, curriculum and personnel can be organised and manipulated to reflect individual needs.

Apart from two outcome studies most findings relate to the use of TEACCH with people with additional learning disability, and the focus of most studies is with children.

The TEACCH structured teaching approach can be regarded as combining a range of prosthetic devices to support the individual with autism to manage their life as independently as possible. Schopler et al. identified studies of differing methods of using structured teaching in non-TEACCH educational programmes with children with a range of diagnoses. All of these studies are reported as supporting the efficacy of structured teaching.

Schopler, Brehm, Kinsbourne and Reichler compared four children with autism in structured and unstructured teaching situations. They found that two of the children learned more in structured situations, these being those children at earlier developmental stages. These results are supported by a larger comparative study in a range of three settings with varying levels of structure. However the presence of a higher initial mean IQ level (66) in the structured group compared to the comparison groups (48 and 52) may have been influential.

Schopler et al. examined parent reports of the effectiveness of structured teaching within the TEACCH programme. Questionnaires from 348 families completed between 1966 and 1977 were analysed. 96% of the families with older children reported that their children were still living in the local community. This compared to between 26% and 61% of adolescents with autism in contemporaneous follow-up studies in other settings.

In a study comparing the behavior of children with autism in the period between referral to a psychiatrist and diagnosis with their behavior during a similar time period after structured teaching had been implemented by parents, Short reported a significant reduction in inappropriate behaviors.

Ozonoff and Cathcart studied two groups of 11 children matched by diagnosis, age and severity of autism. One group provided a control, receiving only a discrete trial school-based programme, while the experimental group received an additional home-based TEACCH programme for 4 months. Pre- and post-testing using PEP-R identified that the experimental group made an overall improvement 3 to 4 times greater than the control group in motor skills, imitation and non-verbal conceptual skills.

A criticism of the evidence base for TEACCH is the lack of independent studies. However a number of studies, notably from Europe and Japan do exist. Notomi reports on five case studies using TEACCH interventions in Japan. In each case the behavior (repeated emptying of a toy box, stripping in class, encopresis, throwing clothing from a high-rise balcony, flooding irrigation systems) was reported as being successfully extinguished. However these were not controlled trials and no standard objective assessment tool was used.

Kielinen et al. found that 43.9% of 187 children with autism aged between 3- and 18-years-old in their study in northern Finland were receiving TEACCH. Though some improvement was reported, results were not significantly higher than for any other intervention identified in the study, and were further compromised by the fact that 82.9% of those in the study were receiving more than one intervention. Similarly Sheehy’s finding of substantial improvements in a range of motor, perception and cognition skills in the Barnardo’s preschool programme in Northern Ireland acknowledges that other strategies were in evidence, compromising the integrity of TEACCH implementation. A reported study from France is also compromised by lack of treatment integrity, using TEACCH approaches in a broader package of intervention.

Sines evaluated classrooms against the Division TEACCH classroom checklist to support intervention integrity. His study involved a convenience sample of 19 children from TEACCH classrooms in four special schools in Northern Ireland. A single pupil from a non-TEACCH classroom was included in the study as a control. In addition six adults with autism and one with a non-specific communication disability were identified by a day service using TEACCH. All parents of the children and adults were interviewed, and 53 professional support staff involved with the participants were sent questionnaires; 28 of these being returned. In measuring the effectiveness of TEACCH, 79% of respondents described TEACCH as effectively reducing inappropriate behaviour. Additionally other areas of improvement were noted by 86% in self-help skills, 73% in social skills, 82% in fine motor skills, 60% in gross motor skills and 90% in communication skills.

Findings supporting the effectiveness of TEACCH programmes were confirmed in a later study comparing a TEACCH programme to a normal Italian school programme (not autism specific) in an evaluative study by Panerai, Ferrante and Zingale. Sixteen participants were allocated to two groups matched by age, gender, IQ and diagnosis. The PEP-R and Vineland Adaptive Behaviour Scales (VABS) were administered at baseline and after a one-year interval. The PEP-R scores of the experimental (TEACCH) group showed statistically significant increase in all categories except fine motor skills. The control group scores showed an increase in hand-eye co-ordination only. The VABS results showed statistically significant improvement in total daily living skills for both groups, but only in the experimental group for overall total. There was no significant change in challenging behavior for either group, though a previous study evaluating the use of TEACCH with 18 children and adolescents with autism reported a notable reduction in challenging behaviors during structured activities compared to during non-structured activities. Although this study did not use a control group, the researchers found overall improvements in behavior and communication after 12 months and 18 months of a TEACCH programme. Alongside the treatment integrity issues highlighted in some independent studies (e.g.  ), therapist drift may also impact on outcome validity. Outside of the controlled environment of Division TEACCH services, a model for supporting integrity of strategies from training room to practice has been proposed by Chatwin and Rattley.

Jordan describes the literature on TEACCH as providing ‘very positive, but not remarkable, results’. Though there are studies involving control groups (e.g. ), thorough scientific validation of the TEACCH approach is scarce. However there has been no objective study finding it to be ineffective, harmful nor leading to unintended consequences. From published reviews of interventions for people with autism a consensus of effective features can be identified. These include parental involvement, early intervention, developing communication skills, joint attention and social understanding; and using the individual’s strengths and interests. In these terms the TEACCH methodology uses appropriate techniques to address appropriate issues.