Treatment and Education of Autistic and Related Communication Handicapped Children
|University of North Carolina School of Medicine|
The University of North Carolina TEACCH Autism Program 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 Eric Schopler and 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 1971 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. Gary B. Mesibov, a professor and researcher on UNC's TEACCH program since about 1979, was director of the program from 1992 to 2010.
With over 40 years of experience of working with autistic people, TEACCH methodology continues to evolve, refining its approach. It is a "pioneering" program for assisting with autism spectrum disorder education, research and service delivery for children and adults.
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 program 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.
Most of the literature is of North American origin. The adoption of the TEACCH approach has been slower elsewhere. 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. In 2003 it was reported that Gary B. Mesibov and Eric Schopler describe TEACCH as the United Kingdom's most common intervention used with children with autism. In Europe and the United States it is also a common intervention.
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.||”|
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 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.
Program effectiveness viewpoints
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.
A recent meta-analysis compiling all the clinical trials of TEACCH indicated that it has small or no effects on perceptual, motor, verbal, cognitive, and motor functioning, communication skills, and activities of daily living. There were positive effects in social and maladaptive behavior, but these required further replication due to the methodological limitations of the pool of studies analysed. These findings, published in one of the most prestigious and rigorous clinical psychology journals, raise questions about the conclusions of reviews that do not use standard methods for compiling scientific evidence.
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- Mesibov GB, Shea V, Schopler E (2004). The TEACCH Approach to Autism Spectrum Disorders. Springer. ISBN 0-306-48646-6.
- Schopler to be honored with APF lifetime achievement award. Archived 2007-03-12 at the Wayback Machine. University of North Carolina Health Care. April 10, 2006. Retrieved September 15, 2012.
- Gary B. Mesibov. Hunter College. Retrieved September 14, 2012.
- Gary Mesibov to step down as director of UNC’s TEACCH program. University of North Carolina School of Medicine. Retrieved September 14, 2012.
- Philosophy and Overview. TEACCH, University of North Carolina School of Medicine. Retrieved September 15, 2012.
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- Eric Schopler; Gary B. Mesibov. Psychoeducational Profile - Revised (PEP-R). Pro-Ed; 1 January 1979. ISBN 978-0-89079-238-4.
- Eric Schopler; Gary B. Mesibov. Autism in Adolescents and Adults. Springer; 28 February 1983. ISBN 978-0-306-41057-4.
- Eric Schopler; Gary B. Mesibov. (editors) Communication Problems in Autism. Springer; 31 May 1985. ISBN 978-0-306-41859-4.
- Eric Schopler; Gary B. Mesibov. Social Behavior in Autism. Springer; 28 February 1986. ISBN 978-0-306-42163-1.
- Eric Schopler; Gary B. Mesibov. Neurobiological Issues in Autism. Springer; 30 April 1987. ISBN 978-0-306-42451-9.
- Gary Mesibov; Eric Schopler. Adolescent and Adult Psychoeducational Profile (AAPEP). Pro-Ed; 1 September 1988. ISBN 978-0-89079-152-3.
- Eric Schopler; Gary B. Mesibov. Diagnosis and Assessment in Autism. Springer; 30 September 1988. ISBN 978-0-306-42889-0.
- Eric Schopler; Gary B. Mesibov. Behavioral Issues in Autism. Springer; 31 March 1994. ISBN 978-0-306-44600-9.
- Eric Schopler; Gary B. Mesibov. Learning and cognition in autism. Plenum Press; 1995. ISBN 978-0-306-44871-3.
- Eric Schopler; Gary B. Mesibov. (editors). Parent Survival Manual: A Guide to Crisis Resolution in Autism and Related Developmental Disorders. Springer; 30 June 1995. ISBN 978-0-306-44977-2.
- Rhoda I. Landrus; Gary B. Mesibov. Structured Teaching. Division TEACCH; 1996.
- Gary B. Mesibov; Lynn W. Adams; Laura G. Klinger. Autism: Understanding the Disorder. Springer; 31 January 1998. ISBN 978-0-306-45546-9.
- Eric Schopler; Gary B. Mesibov; Linda J. Kunce. Asperger Syndrome or High-Functioning Autism?. Springer; 30 April 1998. ISBN 978-0-306-45746-3.
- Gary B. Mesibov; Victoria Shea; Lynn W. Adams. Understanding Asperger Syndrome and High Functioning Autism. Springer; 31 August 2001. ISBN 978-0-306-46626-7.
- Gary Mesibov. Accessing the Curriculum for Pupils with Autistic Spectrum Disorders: Using the TEACCH Programme to Help Inclusion. Taylor & Francis; 20 June 2003. ISBN 978-1-85346-795-0.
- Gary B. Mesibov; Victoria Shea; Eric Schopler. The TEACCH Approach to Autism Spectrum Disorders. Springer; 7 December 2004. ISBN 978-0-306-48646-3.
- Gary Mesibov. AAPEP. PRO-ED; 2007
- Gary Mesibov; John B. Thomas; Michael Chapman. Teacch Transition Assessment Profile (TTAP). Pro Ed; 31 December 2007. ISBN 978-1-4164-0193-3.
- Ruth Aspy; Barry G. Grossman; Gary B. Mesibov, Ph.D. (FRW). Designing Comprehensive Interventions for High-Functioning Individuals with Autism Spectrum Disorders: The Ziggurat Model. Autism Asperger Publishing Company; 31 August 2011. ISBN 978-1-934575-96-3.
- Gary Mesibov; John B. Thomas; Michael Chapman. Teacch Transition Assessment Profile, Computer Version (Ttap-cv): Computer Version. Pro Ed; 30 March 2012. ISBN 978-1-4164-0501-6.
- The program web site at University of North Carolina
- A basic overview of TEACCH by Paul Trehin of Autisme France
- All join in - Ideas for structuring learning for children with autistic spectrum disorders