Clinical & Counselling Psychology Review (CCPR)

Volume 5 Issue 1, Spring 2023

ISSN(P): 2412-5253 ISSN(E): 2706-8676
Homepage: https://journals.umt.edu.pk/index.php/CCPR

Article QR

Use of Behavioral Modification and Sensory Integration Strategies to

Title:
Manage Symptoms of Autism Spectrum Disorder (ASD)

Author (s): Hareem Jamil, Zarmin Tariq, Nazia Bashir

Affiliation (s): University of the Punjab, Lahore, Pakistan

DOI: https://doi.org/10.32350/ccpr.51.05

History Received: December 14, 2022, Revised: May 07, 2023, Accepted: May 25, 2023

Jamil, H., Tariq, Z., & Bashir, N. (2023). Use of behavioral modification
Citation: and sensory integration strategies to manage symptoms of autism
spectrum disorder (ASD). Clinical and Counselling Psychology
Review, 5(1), 76-95. https://doi.org/10.32350/ccpr.51.05
Copyright: © The Authors
Licensing: This article is open access and is distributed under the terms of
Creative Commons Attribution 4.0 International License
Conflict of
Interest: Author(s) declared no conflict of interest

A publication of
Department of Clinical Psychology
University of Management and Technology, Lahore, Pakistan
 Use of Behavioral Modification and Sensory Integration Strategies to
Manage Symptoms of Autism Spectrum Disorder (ASD)
Hareem Jamil*, Zarmin Tariq, Nazia Bashir
Centre for Clinical Psychology, University of the Punjab, Lahore
Abstract
Autism spectrum disorder (ASD) is a neurodevelopmental condition
characterized by symptoms in two domains: Social communication/social
interaction and restricted, repetitive patterns of behavior, interests, or
activities. The impairments associated with ASD often become
challenging in the clinical setting due to their broader impact across
developmental domains. Therefore, recent evidence suggests a
combination of behavioral and sensory integration strategies in managing
ASD. Several carefully designed interventional studies have also provided
information about the effects of caregiver training and direct instruction at
the interventional level. The current study presents the case of a four years
and six months old boy who was referred with complaints of poor
socialization and communication and repetitive behaviors. This study was
based on a single case-ABA design. Initial assessment of the client
involved several steps including a clinical interview, behavioral
observation, administration of Sensory Screening Checklist followed by a
diagnostic assessment based on the Childhood Autism Rating Scale
(CARS 2) and diagnostic criteria provided by DSM-5 TR. Based on the
assessment, the diagnosis of ASD was confirmed and a management plan
was formulated to address the presenting issues. A total of 26 therapy
sessions were carried out with the client that particularly focused on
managing repetitive behaviors using a combination of behavioral and
sensory integration strategies. Outcome analysis revealed that the client
demonstrated a reduction in behaviors including teeth grinding and
echolalia. The therapy sessions proved beneficial in addressing the client's
challenges, albeit with further work needed to achieve optimal outcomes.
Keywords: autism/ASD, behavioral management, echolalia, sensory
integration, sensory needs, teeth grinding

*
Corresponding Author: [email protected]
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Introduction
Autism spectrum disorder (ASD), characterized by deficits in social
communication, repetitive behaviors, and narrow interests; typically
presents itself in one of three distinct onset patterns: Early onset,
regressive onset, or plateau onset. Early onset refers to the emergence of
symptoms within the first year of life, while regressive onset entails a loss
of previously acquired social and communicative skills typically occurring
in the second or third year. Conversely, plateau onset describes a
developmental trajectory where progression beyond initial year stagnates,
despite the retention of previously acquired skills (Boterberg, 2019).
Recent evidence based on a review of epidemiological studies suggests
that ASDs are prevalent conditions, with a globally estimated prevalence
of 7.6 cases per 100 (one in 132), (Alrehaili et al., 2023). It is regarded as
a lifelong complication and has a complex etiology that involves an
interplay of genetic, neurobiological, and environmental factors (Moussa
et al., 2016). A growing literature supports fetal origins and also looks into
various maternal conditions such as gestational diabetes, hypertension,
medications, etc. (Lyall et al., 2017; Moussa et al., 2016). One of these
potential risk factors is the mother’s age. Evidence suggests an association
between advancing maternal age and autism (Lyall et al., 2017). The
findings have also shown a U-shaped relationship between these two
variables. This implies that the chances of having an offspring with
autistic traits are comparable in both younger and older mothers, with a
higher risk among mothers who have autistic traits (Sari et al., 2022).
Considering the complexity of ASD, the diagnosis of autism provided
by Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association [APA], 2013, 2022) criteria for ASD aim to make
a clearer distinction between the underlying neurobiological causes and
the observable behavioral symptoms. This allows individuals
demonstrating the characteristic behavioral patterns of ASD from early
childhood to receive a diagnosis of ASD, while also facilitating the
identification of additional biomedical conditions (Lord & Jones, 2023).
In addition to behavioral difficulties, sensory issues are a common
presentation in ASD. Sensory processing can be difficult among children
with autism, especially insensitivity or extreme sensitivity to sensory input
from the environment (APA, 2013). These difficulties are likely to

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exacerbate already existing communication and anxiety among these

children (Khaledi et al., 2022). These atypical patterns of sensory
responsiveness may cascade into other domains of development and can
significantly predict aspects of adaptive behaviors in children with ASD
children (Williams et al., 2018). It has been observed that sensory
impairments are often linked to problematic behaviors such as lethargy,
irritability, hyperactivity, noncompliance, stereotypic behaviors, and
speech issues which could be difficult to deal with (O’Donnell et al., 2012;
Dellapiazza et al., 2020). It is likely that a repetitive or stereotypic
behavior is functionally related to sensory sensitivity and is performed to
cope with hyper or hyposensitivity in the environment (Kapp et al., 2019).
So, atypical sensory processing seems to be an important contributor to the
severity of ASD symptoms as well as the rate of acquisition of
communication skills (Feldman et al., 2020). In general, this suggests a
significant association between sensory impairments and communication
difficulties (Khaledi et al., 2022) highlighting the need to focus on the
sensory needs of autistic children at the interventional level along with
communication and behavioral issues.
The fusion of behavioral extremes, known as behavioral excesses and
deficits, often results in a repetitive and limited pattern of vocal behavior,
for instance, echolalia (Edelstein et al., 2021). Echolalia is commonly
described as the socially awkward or inappropriate repetition of all or part
of a previously spoken phrase (Valentino et al., 2012). While some
repetition of language is typical in child development, children with ASD
may persist in echolalia beyond early childhood. Moreover, they may
exhibit echolalia devoid of social context and at a higher frequency
compared to typically developing children (Howlin, 1982). Echolalia can
(a) pose challenges to educational interventions aimed at speech
improvement, (b) contribute to breakdowns in communication, (c)
heighten the risk of social isolation or stigma, and (d) increase the
likelihood of challenging behaviors (Valentino et al., 2012). Similarly,
another common example is teeth grinding behavior also known as
bruxism (Kandaswamy, 2017). The association between bruxism/teeth
grinding and problems with sensory processing in autistic children has
been examined. Children with autism had a higher chance of developing
bruxism when they had problems in their sensory processing. Bruxism
may arise in this population as a result of sensory sensitivity and the

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neurobiology between the connection of the gut and the brain

(Kandaswamy, 2017).
Considering the challenges associated with ASD, modes of
intervention are available; however, among these, early intensive
behavioral intervention emerges as the sole empirically validated avenue
for enhancing cognitive abilities in individuals with ASDs (Tromans &
Adams, 2018). Although a handful of medications exist to mitigate
symptoms like aggression, irritability, and hyperactivity, the cornerstone
of ASD treatment predominantly rests upon behavioral strategies. The
behavioral component encompasses a spectrum of approaches aimed at
increasing positive behaviors through educational techniques, tailored
learning opportunities, and modifying contingencies and associations
(Whitehouse et al., 2020).
In recent years, meticulously crafted intervention studies have shed
new light on the efficacy of various components within behavioral
treatments, encompassing caregiver training, and direct instructional
methods (Sandbank et al., 2023). However, assessing the impact of these
interventions proves to be a nuanced endeavor, contingent upon the unique
characteristics of the child in question as well as the skills and attitudes
within the family dynamic. Interestingly, disparate interventions targeting
distinct skills may yield comparable outcomes, underscoring the
complexity of effective intervention strategies (Kasari et al., 2012). To
that end, Al- Dawaideh (2014) identified two interventions as having
initial evidence supporting their efficacy in addressing echolalia: The
cues-pause-point and more general verbal prompting interventions. The
cues-pause-point intervention is a behavioral approach that has been
studied for management of immediate echolalia. Originally introduced by
McMorrow and Foxx (1986) during the treatment of a 21-year-old male
with ASD, this intervention involves the presentation of a visual cue by a
trainer followed by instructions regarding the upcoming teaching session.
Subsequently, the trainer poses a question and allows for a brief pause.
Finally, the visual cue is pointed to prompt the learner to verbalize the
answer to the question (Neely et al., 2016). This emphasizes the usefulness
of strategies involving direct instructions to or involvement of the client in
the management of ASD e.g., addressing speech difficulties. Similarly for
sensory impairments which are common presentations in ASD, sensory
integration interventions that also focus on client-directed activities and

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caregiver engagement (Little et al., 2022; Pfeiffer et al., 2011) are

established to improve difficulties associated such as attention span,
speech, and understanding (Jamal Uddin et al., 2021). As in the case of
bruxism/ teeth grinding, function-based stimulation intervention produced
substantial decreases in teeth grinding among autistics (Scarff, 2016). It
has been observed that sensory integration strategies are more effective
than behavioral modification methods. However, a combination of
behavioral and sensory integration strategies is likely to be more
promising in managing difficulties associated with autism (Jamal Uddin et
al., 2022).
The above mention literature holds significant implications for
intervention strategies, underscoring the imperative of precisely targeted
behavioral or language-focused interventions during the early
developmental stages, even among children exhibiting milder
manifestations of ASDs. Moreover, analyses of longitudinal data
underscore the transformative impact of sustained caregiver involvement
in parent-mediated interventions during the formative early preschool
years. Whether through coaching or direct instruction on interacting with
their children, caregivers who remained engaged in such interventions
witnessed marked enhancements, nearing almost a standard deviation, in
language and adaptive skills throughout the school years, in contrast to
caregivers who did not participate (Anderson et al., 2011). However, scant
evidence exists that employed a combination of behavioral and sensory
strategies in managing difficulties associated with autism, e.g., teeth
grinding and echolalia. Therefore, the present study examines a
combination of these strategies in managing the behavioral difficulties
associated with ASD.
Clinical Case Description
The client was a four year and six months old boy. He was referred by
his teacher for assessment of complaints such as poor communication and
socialization, repetitive behaviors including teeth grinding, and echolalia
of last spoken word/sound. The client lived in a nuclear family system
with his mother and three sisters, while his father has been living abroad
due to his job. He reported having a satisfactory relationship with his
parents and three elder sisters. It was informed that the client’s mother had
a stressful pregnancy and experienced complications at the time of birth
due to her age as she was in her 40s, however, the client was a healthy
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child at the time of his birth. It was reported that since the client’s birth,
his family was living abroad; however, they had to move back to Pakistan
with his mother and sisters following COVID-19. Before the pandemic
when the client was about two and a half years old, he was an active
healthy child. However, due to the pandemic situation, the client was
restricted to his home and could only socialize with his immediate family.
Furthermore, the client’s family experienced some financial difficulties
upon which they had to move back to Pakistan. The client was three years
old at that time. Soon after the client moved back, he experienced
difficulties in adjusting to the new environment as well as due to the
absence of his father. Although client used to socialize and interact with
people in his immediate circle like other children of his age, however, at
that time he often showed tantrums and disliked interacting with
relatives/acquaintances and playing with children of his age. He also
experienced speech regression which remained non-concerning for the
family. However, when the client became three and a half years old, these
issues remained and his family sent him to an institute, for his regressed
speech and behavioral difficulties, at the suggestion of a psychiatrist and a
clinical psychologist where he received regular sessions for three months.
Relying on the slight improvement in tantrums, his parents decided to send
him to kindergarten at the age of four years. The client’s social and
communication difficulties worsened when he had to relate with his peers
and participate in the classroom. Considering the client’s repetitive
behaviors and poor language ability, compared to the children of his age,
his teacher referred him for the clinical assessment. Presently, this case is
focusing on interventions employed for sensory concerns, teeth grinding
behavior, and echolalia in the client.
Initial Screening
The initial screening of the client was done through a clinical
interview with his mother, behavioral observation, baseline for teeth
grinding, and reinforcer identification.
Table 1
Possible Factors Underlying Client’s Condition
Mother’s stress and high blood pressure during
Predisposing
pregnancy
factors
Mother’s age at the time of pregnancy

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Lack of opportunities to socialize during

Precipitating and
lockdown due to COVID-19
Maintaining factors
Adjustment problems on moving back to Pakistan
Early intervention
Protective factors
Family’s concern

Behavioral Observation
The client was a physically healthy child with age-appropriate height
and weight. He greeted the therapist with a handshake and maintained
appropriate eye contact when directed by his mother. However, when tried
to engage in a conversation or addressed directly, he often lowered his
gaze, showed an indifferent attitude, or gave odd responses by making
loud noisy sounds. He often engaged in repeating the last word/sound of a
sentence said in front of him. When observed during play activities, he
preferred playing alone and used color-sorting puzzles while also grinding
his teeth during play. He displayed a good one-word vocabulary, named
animals with toy prompts, and sniffed objects. He repeatedly checked his
mother's bag for food and cried when denied. The echolalia and teeth
grinding behaviors were observable throughout the session and were
present even when the client was not directly involved in a conversation or
any activity.
Baseline for Teeth Grinding
The mother was provided with a baseline assessment to monitor teeth
grinding behavior displayed by including. This behavior was characterized
by clenching or moving the lower jaw to produce sounds as the teeth
rubbed together.
Table 2
Pre-Assessment of Teeth Grinding
Teeth Grinding Rating (pre-assessment)
7 times (when not involved in any tasks)
Average Frequency
3 times (when involved in a task)
Average Intensity 7
Average Duration 10 seconds

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Baseline for Echolalia

A baseline assessment to monitor echolalia was done. This behavior
was characterized by the client’s repetition of words spoken by an adult in
an hour.
Table 3
Pre-Assessment of Echolalia
Echolalia Rating (pre-assessment)
6 times (when not involved in any tasks)
Average Frequency
4 times (when involved in a task)
Average Duration 13 seconds
Sensory Screening
Sensory Screening Checklist. This checklist is described as a
preliminary non-diagnostic assessment tool designed to identify a child's
sensory processing preferences, patterns, and sensitivities. It consists of
categories representing various sensory modalities and behaviors
commonly associated with sensory processing challenges. Its scoring
typically involves checking the items to each category in either the hyper-
responsive or hypo-responsive domain based on observed behaviors.
These scores reflect the frequency, intensity, or severity of sensory
processing difficulties within each modality (Aquilla et al., 2015).
Table 4
Categories and Description of Sensory Screening Checklist
Auditory Behaviors Hypo-responsive
Proprioception Behaviors Hypo-responsive
Gustatory (Smell/Taste) Hyper-responsive
Tactile Behaviors Hyper-responsive
Vestibular/Balance Hyper-responsive
Visual Behaviors Hypo-responsive
Reinforcer Identification
The identification of reinforcers is important to increase the frequency
of desired behavior (Gomez & Cooper, 2008). In identifying reinforcers
for individuals with neurodevelopmental disabilities, the client's mother
identified tangible items and discussed his preferences, including colors,
chips, and biscuits. Colors were incorporated into therapy, while chips and

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biscuits were initially used as reinforcers to engage him in writing tasks.

Eventually, the use of tangible reinforcers will transition to the client's
preferred "thumbs up" gesture.
Diagnostic Assessment
The diagnostic assessment of the client was done through the
Childhood Autism Rating Scale (CARS 2; Schopler et al., 2010) and the
criteria of DSM-5-TR (APA, 2022).
The Childhood Autism Rating Scale (CARS 2; Schopler et al., 2010)
CARS 2 was used to assess the symptoms of the client. It is a validated
15-item rating scale used to differentiate children with autism from those
with developmental disabilities. It offers objective ratings based on
behavioral observation, with total scores ranging from 15 to 60. A cut-off
score of 30 is typically used to diagnose autism (Schopler et al., 2010). In
the present case, the client’s score suggested that he has mild to moderate
autism.
Table 5
Total Raw Scores and Category on CARS 2
Raw scores Category
30 Mild to Moderate
Procedure
A total of 26 sessions were held, with each session lasting 60 minutes
and tasks being divided accordingly (at both individual and group levels).
The management plan was developed by the client's behavioral difficulties
that had a significant impact on his social and communication skills. The
activities were divided into an hour with tasks devoted to enhancing his
performance in developmental domains such as language as well as
addressing his sensory needs using behavior modification and sensory
integration techniques. Following the completion of the client session, the
mother was given parental training and homework assignments.
Intervention
Rapport Building. Reciprocity and pairing were employed to
establish rapport with the client, involving actions such as imitating his
behavior and engaging in preferred activities. Utilizing the client's
preferred reinforcers, such as coloring and painting, helped foster comfort.
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Singing his favorite poems together further eased the atmosphere, leading
to increased interaction and happiness at the start of therapy sessions.
Behavior Modification Techniques. In an effort to facilitate the client
with echolalia, cue-pause-point (CPP), natural language paradigm, and
verbal modeling plus positive reinforcement for appropriate responses
were used.
Cues-pause-point was introduced by McMorrow and Foxx (1986).
The cues-pause-point intervention consists of the therapist providing a
visual cue to the client to remain silent (cue). During the administration of
this technique, the therapist provided a visual cue to the client and
simultaneously provided instructions regarding the correct response. For
example, the therapist posed the question “What is your name?” and
provided a short pause following the question (pause). If the client
repeated the question, he was the verbal prompt of “No” to make him stop.
Finally, the therapist pointed to a page with his name written or his picture
to prompt the client to verbalize the answer to the question with his name
(point).
Modeling in the form of recasting was also used with the client to
increase his speech and lower the frequency of echolalia. In recasting, the
therapist repeated an error utterance back to the client with the error
corrected. The mother was also instructed to correct the child whenever he
was interacting with the mother.
Differential reinforcement of lower rates of behavior was used to
reduce the repeating behavior of teeth grinding. The client was presented
with a verbal cue, “no grinding”, paired with the touch of the therapist’s
index finger on his chin with a gentle push downwards to cue him to open
his mouth for 10 seconds. If resistance was met the cue was re-presented
only once. The client was given reinforcement when he stopped. He was
introduced to competing behaviors of eating carrots, cucumbers, hard
vegetables, and fruit to fulfill his sensory needs. Additionally, this
technique was also used to foster his social and communication skills such
as reinforcing the client’s interaction with peers and others, responding to
instructions, etc. This was done in collaboration with other therapists
through planning group sessions.
Sensory Integration Activities. To address the client's oral
hyposensitivity, sensory integration activities were introduced
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(Glennon, 2021). The client's mother received instruction on performing

gum massages through instructional videos, which were encouraged to be
incorporated into the client's daily routine. Additionally, the use of a
teether and vibrating toothbrush was recommended. The mother was
advised to provide vegetables such as carrots and cucumbers for the client
to chew when the frequency of teeth grinding increased.
Outcomes of Interventions
After completing a total of 26 sessions with the client, a
comprehensive assessment was conducted to evaluate his progress. The
client's prognosis was assessed as fair, indicating a positive trajectory.
Satisfactory progress was observed across the targeted domains. The
reduction in repetitive behaviors was significant as teeth grinding showed
a notable decrease. This decline was substantiated by reports provided by
both the client's mother and sisters. Additionally, there was a discernible
decrease in echolalia tendencies, indicating improvement in
communication patterns. The positive outcomes observed after the
intervention period reflect the effectiveness of the implemented strategies
and interventions. These findings provide optimism for continued progress
and development in the client's journey toward improved communication
and behavior management. Furthermore, strides in socialization were
evident as the client began to engage more with his siblings and peers,
displaying a newfound willingness to share belongings. Alongside his
progress, the client's mother demonstrated commendable commitment,
actively engaging in the therapeutic process. Early counseling sessions
regarding autism proved beneficial, assuaging her anxieties about her son's
condition, and fostering a sense of resilience and optimism. This
newfound motivation empowered her to remain steadfast in her support
for her son throughout his journey.
Post-Assessment for Teeth Grinding and Echolalia
Table 6
Post-Assessment of Teeth Grinding
Teeth Grinding Rating (mid-assessment)
3 times (when not involved in any tasks)
Average Frequency
0 (when involved in a task)
Average Intensity 3
Average Duration 10 seconds
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Table 7
Post-Assessment of Echolalia
Echolalia Rating (pre-assessment)
3 times (when not involved in any tasks)
Average Frequency
1 times (when involved in a task)
Average Duration 9 seconds
Discussion
The present case study presents the use of behavioral modification and
sensory integration strategies that were expertly employed to address the
client's behavioral challenges. The study provides evidence to use a
combination of behavioral and sensory integration strategies as promising
to manage symptoms or problematic behaviors associated with autism
which is also evident by existing literature (Jamal Uddin et al., 2021). It
also focuses on the use of direct instructions and client-caregiver
involvement in achieving ultimate therapeutic outcomes (Little et al.,
2022; Pfeiffer et al., 2011). Present findings underscored the overall
efficacy of behavioral and sensory interventions in mitigating problem
behaviors among individuals with autism. Notably, in tackling the issue of
echolalia, the implementation of the cue-pause-point (CPP) technique
yielded promising results, indicative of tangible improvements in the
client's condition. Indeed, preceding studies, as noted by Valentino et al.
(2012) and Al-Dawaideh (2014), have demonstrated the applicability of
the cue-pause-point (CPP) procedure in effectively reducing echolalia
during echoic training while concurrently bolstering correct responding.
Furthermore, the efficacy of the CPP procedure extends beyond singular
targets, as evidenced by its ability to swiftly induce behavioral changes
across subsequent objectives.
Addressing the client's repetitive behaviors, such as teeth grinding,
involved the strategic application of differential reinforcement. Existing
literature, as expounded by Efaw (2021), acknowledges both techniques as
effective in facilitating skill acquisition. However, the differential
reinforcement approach emerges as the more dependable method,
consistently yielding favorable outcomes. Preliminary findings, therefore,
advocate for the adoption of the differential reinforcement of unprompted
responses as the default approach in instructing children with autism.

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To manage the client's oral hyposensitivity, sensory integration

activities were utilized, unveiling a significant positive impact on his
behavioral patterns (i.e., teeth grinding). Research insights, as elucidated
by Park & Kong (2015), affirm the efficacy of sensory integrative
interventions in eliciting notable improvements in motor performance and
effecting sensory-based and behavioral changes. However, it's worth
noting that these interventions may not necessarily translate into
enhancements in academic skills.
Integral to the therapeutic process was the active involvement of the
client's family, a component supported by extensive research findings.
Garbacz et al. (2016) highlight the myriad benefits associated with family
engagement in therapy, citing enhanced academic achievement, decreased
levels of problem behavior, and heightened social-emotional skills among
children, both with and without ASD. Thus, the inclusion of the client's
family in the therapeutic journey is not only empirically supported but also
holds promise for fostering positive outcomes.
Limitations
The generalizability of the present case study is concerning since it is
based on a single subject. In addition, it relies on subjective measures of
evaluation. Further, it presents a case of a client with mild to moderate
autism, however, different findings may be observed with varying severity
of autism.
Conclusion
The significance of thorough assessments and individualized
intervention strategies for individuals with ASD is demonstrated by this
case study. The effectiveness of behavioral modification strategies in
combination with sensory integration techniques and CPP intervention
concludes the usefulness of these integrated interventions in treating the
main symptoms of ASD rather than solely relying on behavioral methods.
Implications and Suggestions
The findings of this study would be useful in developing
individualized treatment plans, clinicians should give priority to
multidimensional evaluations such as behavioral observation, diagnostic
testing, and family interviews. For circumstances comparable to this,
clinicians ought to think about implementing these evidence-based
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strategies into intervention procedures. For those with ASD, early

detection and intervention are essential to achieving the best possible
results. This study underlines the advantages of starting therapy early and
the possibility for major advancement with focused interventions during
crucial developmental stages. Future research could examine the value of
customized treatment programmes, the efficacy of combined
interventional strategies, and the impact of therapy on broader
developmental domains. Additionally, a larger sample size and following
proper interventional protocols would be beneficial to collect data related
to the generalizability of the study findings.
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