Some Treatments Available to Consumers in 2008 … · Pyramid Method Lovaas Therapy ... programs...

Research in the Treatment of Autism August 4, 2008

David Celiberti, Ph.D., BCBA

Research in the treatment ofautism: Where are we now and

where should we be going?

David Celiberti, Ph.D., BCBAPresented at Progress Through Partnership:

Pennsylvania's 11th Annual National Autism ConferenceAugust 5, 2008

Facilitated Communication

Precision Teaching

Dolphin Therapy

Discrete Trial Instruction

Pivotal Response TrainingOption Therapy

Dietary Modifications

Prism Glasses

Incidental Teaching

Fluency based Instruction

CABAS

Pyramid Method

Lovaas Therapy

Miller Method

Functional Communication Training

Gentle Teaching

Natural Language Paradigm

Natural Environment Training

Vitamin Therapy

Facilitated Communication

Greenspan’s Floortime

TEACCH

Sensory Integration Training

Some Treatments Available to Consumers in 2008Some Treatments Available to Consumers in 2008

Shaping and ChainingDirect Instruction

Task Analysis

Psychoanalytic Play Therapy

Weighted Vests

Auditory Integration Training

Secretin

Patterning

Holding Therapy

Drug Therapy

PECS

Verbal Behavior Method

RDI

Applied Verbal Behavior

Brushing Therapy Therapeutic Contact with AnimalsCranial-sacral Therapy

Hyperbaric Chamber

Chelation

Secretin

Rebirthing

Fast ForWord

Prompt Technique

Rapid Prompting

Commitment toCommitment toScienceScience BasedBased

TreatmentTreatment

Science-based Education and Treatment• Technology is constantly evolving.

• Best practices are constantly evolving as well.

• What is considered an “appropriate” educationor treatment must similarly evolve over time.

Science-based Education and TreatmentWhy is this essential?• Multiple benefits exist when individuals with autism

receive the MOST EFFECTIVE intervention:– quality of life for child– quality of life for family– Improved long term prognosis– allocation of special education resources– reduced financial expenditures and allocation of

special education resources– broader range of employment opportunities

Science-based Education and TreatmentWhy is this essential?

• Individuals with autism subjected to:– Stagnated methods– Ineffective methods– Providers unaware of scientific advances– Providers unwilling to incorporate scientific

advances– “One size fits all” programming

…..will unlikely realize their fullest potential



Diverse Responses to“New” Methodologies

• Embrace wholeheartedly• Reject outright/ Ignore advances altogether• It is Quantity NOT Quality (“The More I do the better

off my child will be.”)• Within the rubric of ABA, putting all your eggs in one

basket.

Is One ABA Technique Enough?

• The complex needs of persons with autismrequires a myriad of techniques

• No single technique is comprehensiveenough to address all deficit areas of autism

Strategies for Evaluating Methodologies

• Adopt a responsible level of eclecticism

• Think in terms of ANDS and not ORS

• Put quality of intervention delivery overquantity of interventions

• Consider available EMPIRICAL research

• Collect data to objectively assess efficacy

Sources of Guidance for Consumers:Websites

• Websites exist to help consumers with decision makingsurrounding the plethora of autism treatments– Association for Science in Autism Treatment:

www.asatonline.org– Cambridge Center for Behavioral Studies:

www.behavior.org– Organization for Autism Research:

www.researchautism.org– Autism SIG:

www.autismsig.org

– Parent Professional Partnership SIG:www.pppsig.org

Sources of Guidance for Consumers:OAR’s Parents Guide to Research

• The Organization for Autism Research (OAR) hascreated a guide for parents to learn how to betterunderstand research and evaluate research studies.

• This booklet includes:– a glossary of terms– an overview of scientific research– information on how to determine if a particular study may or

may not be pertinent to a particular child– and questions to ask with respect to treatments, therapies, and

other methodologies under consideration

• If you would like to download this free guide from theOAR website, please visit:http://www.researchautism.org/resources/reading/index.asp

The Road Less Traveled: Charting a ClearCourse for Autism Treatment

• The authors:– David Celiberti, Ph.D., BCBA– Suzanne Buchanan, Psy.D., BCBA– Felicia Bleecker, Psy.D.– David Kreiss, Psy.D.– David Rosenfeld, Psy.D.

• See:– http://www.researchautism.org/uploads/road

less.pdf for more information



The Road Less Traveled: Charting a ClearCourse for Autism Treatment

• This paper was written:– To help parents navigate through the myriad

interventions that are proposed for the treatmentof autism.

– To provide a framework for parents with a step bystep approach to selecting treatments.

– To increase the chances that parents will makethe most informed and effective decision for theirchild.

Phases of Inquiry• PHASE I: Exploring the viability and appropriateness

of a treatment approach

• PHASE II: Assessing the appropriateness andapplicability of the intervention under the supervisionof a specific service provider for a specific individualwith autism

• PHASE III: Monitoring the implementation of thetreatment and evaluating efficacy

National Research Council Recommendations

Early Intervention Intensive Intervention (25 hours per week, year round) Planned teaching One-to-One or Small Group Instruction to Facilitate

Acquisition of Individualized Goals Use of specialized techniques such as DTI, Incidental

Teaching Systematic and Individualized Instruction

National Research Council. (2001). Educating children withautism. Committee on Educational Interventions for Childrenwith Autism, C. Lord & J. P. McKee (eds.), Division ofBehavioral and Social Sciences and Education. WashingtonDC: National Academy Press.

National Research Council Recommendations

Emphasis on development of spontaneous socialcommunication, adaptive skills, appropriate behavior,flexibility, play and leisure skills

Monitoring of progress Promotion of generalization Opportunities to interact with typically developing

children (as is appropriate)

“Proven Education Methods”One of the 4 Pillars of No Child Left BehindNo Child Left Behind• Stronger Accountability for Results• More Freedom for States and Communities• Proven Education Methods• More Choices for Parents

• The No Child Left Behind Act of 2001, calls for the useof "scientifically based research" as the foundation foreducation programs and for classroom instruction.

• See http://www.ed.gov/nclb/overview/intro/4pillars.html

“Proven Education Methods”One of the 4 Pillars of No Child Left BehindNo Child Left Behind

• No Child Left Behind was intended to differentiate whicheducational programs and practices have been proveneffective through rigorous scientific research.

• Federal funding was also intended to support thoseprograms and teaching methods that work to improvestudent learning and achievement.

• There has not been much development of this agendawithin the last 5 years.



Maine’s MADSEC Report

• The Autism Task Force of MADSEC (MaineAdministrators of Services for Children with Disabilities)performed a detailed analysis of methodologies withwhich to educate children with autism.

– ABA was the only treatment substantiated to beeffective based on the scope and quality of research.

– This does not mean that ABA is the only interventionthat is effective, just demonstrated to be effective.

– The February 2000 MADSEC document can be found athttp://www.madsec.org/docs/ATFReport.pdf


• The Autism Task Force of MADSEC characterizedinterventions in one of 4 ways:– objectively substantiated as effective– anecdotally showed promise, but not objectively

substantiated– research shows that intervention is not effective,

may be harmful, or lead to unintendedconsequences

– be without scientific evaluation of any kind


• The Autism Task Force of MADSEC suggests thatprofessionals endorsing a specific intervention haveethical responsibility to:– accurately describe research (or lack thereof)– refrain from exaggerated claims of effectiveness– portray method as “experimental” and disclose this

status to key decision makers

Maine’s MADSEC Report• MADSEC 2000 Findings:

– Objectively substantiated as effective• Applied Behavior Analysis

– Anecdotally showed promise, but not objectivelysubstantiated at that time

• Auditory Integration Training, Miller Method, Sensory Integration,TEACHH

– Research shows that intervention is not effective, may beharmful, or lead to unintended consequences

• Facilitated Communication

– Without scientific evaluation of any kind at that time• Greenspan’s Floortime, Son-Rise

New York’s Department of Health Report– ABA was the only treatment substantiated to be

effective based on the scope and quality of research.

– Again, this does not mean that ABA is the onlyintervention that is effective, just demonstrated to beeffective.

– Information about the New York State document canbe found athttp://www.health.state.ny.us/community/infants_children/early_intervention/autism/index.

New Jersey Department of Education• In the Fall of 2004, the New Jersey Department of

Education, Office of Special Education publishedAutism Program Quality Indicators lists unsupportedtreatments.

• Seehttp://www.celebratethechildren.org/Documents/Indicators.pdf



International Efforts• It would be important to acknowledge efforts

abroad. Reviews of the available research have alsobeen conducted in Australia at the University ofSidney.

• The February 2004 document was prepared for theDepartment of Ageing, Disability, and Home Careand reviewed the research on the vast array ofautism treatments.

• The report can be found athttp://www.autismnsw.com.au/resources/ASDreview.pdf.

American Academy of Pediatrics• American Academy of Pediatrics acknowledged the

growing body of evidence that intensive earlyintervention services for children in whom autism isdiagnosed before 5 years of age leads to better overalloutcomes.

• They did not review the broader ABA literature.

• Their report can be found atpediatrics.aappublications.org/cgi/reprint/107/5/e85.pdf

American Academy of Pediatrics• American Academy of Pediatrics further acknowledged

that:– Controversial, nontraditional therapies will continue

to proliferate– Parents will seek input from pediatricians– Pediatricians must be prepared to discuss directly

and carefully

American Academy of Pediatrics• More specifically, pediatricians were advised to:

– Promote access to proven methodologies– Be involved in all treatment decisions even when faced

with disagreements– Discuss alternative therapies initially and frequently and

remain current on these treatments– Clarify that discussion of these should not be

misconstrued as endorsement– Discussing the placebo effect and the importance of solid

research– As needed, set up a trial of therapy with clear treatment

objectives and adequate data collection to assess benefit

American Academy of Pediatrics• More specifically, pediatricians were advised to:

– Promote access to proven methodologies– Be involved in all treatment decisions even when faced

with disagreements– Discuss alternative therapies initially and frequently and

remain current on these treatments– Clarify that discussion of these should not be

misconstrued as endorsement– Discussing the placebo effect and the importance of solid

research– As needed, set up a trial of therapy with clear treatment

objectives and adequate data collection to assess benefit

The Association for Sciencein Autism Treatment (ASAT)

• ASAT is a national, not-for-profit, 501(c) 3organization.

• ASAT is committed to sciencescience as the most objective,time-tested and reliable approach to discerningbetween safe, effective autism treatments, and thosethat are harmful or ineffective.

• ASAT supports all scientifically sound research onthe prevention, treatment and cure of autism, as wellas all treatments for autism that are shown to beeffective through solid scientific research, regardlessof discipline or domain.



ASAT: Our Mission• Disseminate accurate, scientifically sound information

about autism and its treatments

• Improve access to effective, science-basedtreatments for all people with autism, regardless ofage, severity of condition, income, or place ofresidence.

ASAT: History• The formation of ASAT in 1998 was necessitated in

part by a long history of failed treatments and fads,levied on vulnerable children and adults, and on theirfamilies.

• From the scandal of the “refrigerator mother” theory,to the ongoing parade of “miracle cures” and “magicalbreakthroughs,” history has been dominated byimprobable theories about causation and treatmentsfounded on speculation and shaky evidence.

ASAT Website• Research Summaries• Library of articles• FAQ and Help Desk• Links and resources• New feature- ASAT Forum• Conference Information

………………We are open to your feedback

ASAT Treatment Summaries• Currently non-behavior analytic, behavior analytic,

and medical treatments are described onwww.asatonline.org

• This is a work in progress!

ASAT Treatment Summaries: Psychological,Educational, and Therapeutic Interventions• Animal Therapy

• Applied Behavior Analysis

• Art Therapy

• Auditory Intergration Therapy (AIT)

• Developmental Therapies (e.g., Greenspan, RDI)

ASAT Treatment Summaries: Psychological,Educational, and Therapeutic Interventions• Facilitated Communication

• Holding Therapy

• Music Therapy

• Oral-Motor Training Therapy

• Patterning

• Picture Exchange Communication System (PECS)



ASAT Treatment Summaries: Psychological,Educational, and Therapeutic Interventions

• Project TEACCH (Treatment and Education of Autisticand related Communication-handicapped children)

• Psychoanalytic and Humanistic Play Therapy

• Recreational Sports/Exercise

• Relationship Development (RDI)

• Sensory Integrative Therapy

ASAT Treatment Summaries: Psychological,Educational, and Therapeutic Interventions

• Socialization related classes

• Social Stories

• Son Rise (Options)

• Video Modeling

• Vision Therapy

ASAT Treatment Summaries:Biomedical Interventions

• Anti-Fungal Medication, Anti-Yeast Medication

• Chelation Therapy

• Craniosacral Therapy

• Herbs and Homeopathic Treatment

• Hyperbaric Oxygen Therapy

ASAT Treatment Summaries:Biomedical Interventions

• Magnets

• Medications

• Special Diets

• Vitamin and Supplement Therapy

ASAT Treatment Summaries:Some Behavior Analytic Interventions

• Activity Schedules

• Direct Instruction

• Discrete Trial Instruction

• Early Behavioral Intervention/Treatment

• Functional Assessment/Analysis

• Functional Communication Training (FCT)


• Incidental Teaching

• Peer Mediated Social Skills Training

• Pivotal Response Training (PRT)/Natural LanguageParadigm

• Positive Behavioral Support

• Precision Teaching/Fluency-Based Instruction




• Self-Management

• UCLA/Lovaas Intervention

• Verbal Behavior/Applied Verbal Behavior

So WHAT isApplied Behavior Analysis?• “The science in which procedures derived from

principles of behavior are systematically appliedto improve significant behavior to a meaningfuldegree and to demonstrate experimentally thatthe procedures employed were responsible forthe improvement in behavior.”

- J. Cooper, T. Heron, and W. Heward, 1987, 2007

Experimental

Behavior Analysis

Applied

Behavior Analysis

Behavior Analysis

Underlying Assumptions ofBehavior Analysis

• Determinism• Empiricism• Scientific Manipulation• Philosophical Doubt

Dimensions ofApplied Behavior Analysis

• Applied• Behavioral• Analytical• Technological• Conceptually Systematic• Effective• Generality

Socially Important Problems(Martin & Pear, 2007)

• Parenting and Child Management• Education: From Preschool to University• Clinical Behavior Therapy• Self Management of Personal Problems• Medical & Health Care• Gerontology and Elder Care• Behavioral Community Psychology• Sports Psychology• Industry



Array of Behavioral and Cognitive ApproachesDerived from Traditional Learning Paradigms

• Respondent conditioning approaches (e.g, systematicdesensitization, exposure and response prevention,relaxation)

• Operant conditioning approaches (e.g., skill training,reinforcement, functional communication training)

• Social learning approaches (e.g., modeling)

• Cognitively-based approaches (e.g., cognitiverestructuring)

Various Applications of Behavior AnalyticMethods to Target Behavior Reduction:

• Restrict or narrow conditions (e.g., settings, situations,persons involved) under which undesired behaviorsoccur

• Reducing motivation to engage in undesired behavior• TEACH a replacement skill• Withhold reinforcement that may have given rise to

undesired behavior• Provide consequences when behavior occurs

Key Elements of Applied BehaviorAnalysis Often Overlooked

• a vast scientific discipline based upon over 50 years ofpublished research

• targets both skill acquisition and behavior reduction• employs both proactive and reactive strategies, and

typically use them concurrently• relies on data collection and evaluation in an ongoing

manner throughout the intervention• determines change in selected, objectively defined target

responses, not by subjective decisions or ambiguousfactors

• Considers generalization to the real life setting andmaintenance over time

Key Elements of Applied BehaviorAnalysis Often Overlooked

• Applied Behavior Analysts develop interventions thatare based upon empirically validated research and bestpractices for both skill acquisition and behaviorreduction.

• Intervention design and implementation relies on ascientific method for both skill acquisition and behaviorreduction (e.g., defining targets, data collection).

• Skill acquisition and behavior reduction efforts are bothvery individualized.

Applied Behavior Analysis as aHumane Approach– Individuals are provided with empirically validated

interventions– Individuals are given skills to be more successful within

their environments– Individuals are given skills to achieve future success in

less restrictive environments– Efforts are made to break learning down into easily

attainable goals– Efforts are made to prevent or delay need for medication

or more restrictive environment– The ongoing analysis of data helps prevent harm to

consumers

Applied Behavior Analysis as aHumane Approach– Functional assessments enable identification of the

underlying communicative intent of challenging behaviors– Functional assessments enable interventionists to

respect goals, while helping the individual develop otherways to meet those goals

– Behavior plans provide individuals with more acceptabletools for negotiating their environment

– In sum, Applied Behavior Analysis is a humane approachbecause nurturing environments are created to helpindividuals realize their fullest potential



Some Common Misconceptions ofApplied Behavior Analysis

• Applied Behavior Analysis is just a fad in the literature.

• Applied Behavior Analysis is based on the work of onlyone individual.

Other Misconceptions Related toBehavior Analysts

• All behavior Analysts are created equal.

• Behavior Analysts are inherently closeminded.

•• Behavior Analysts are, by nature, cold and

mechanistic.

• If you have heard one Behavior Analyst youhave heard them all.

Other Misconceptions Related toBehavior Analysts

• Behavior Analysts are all autism experts.

• Certification in Behavior Analysis issynonymous with being an autism expert.

• Behavior Analysts only use discrete trialinstruction.

Some Behavior AnalystsCause Divisiveness

• A number of Behavior Analysts dismiss outrightany and all alternative interventions.– Other members of a multi-disciplinary team

may feel alienated or dismissed– As a result, some parents become more

careful about pursuing unvalidatedinterventions.

– Some parents are alienated by such harshpositions and pursue other interventionssecretly.

• Unfortunately, this runs counter to the concept ofparent-professional partnership.

ABA has been show to positively impact abroad array of skills in persons with autism• Skill areas:

• Language• Social• Cognitive• Motor• Coping• Academic• Leisure• Vocational• Self control• Self-care and functional life skills

ABA can target a broad array of challengingbehaviors in persons with autism

• Disruptive behavior• Destructive behavior• Noncontextual verbalizations or vocalizations• Stereotypic behavior• Self-injurious behavior• Aggression• Rituals, compulsions, preseverative behavior• Atypical reactions to sensory stimuli• Atypical reactions to changes in the environment or routines• Active and passive non-compliance



Various Applications of Behavior AnalyticMethods to Target Skill Acquisition:

• Establish/Target NEW skills

• Teach discrimination

• Maintain already acquired skills

• Promote Generalization (both stimulus and response)

A Non-exhaustive List of TeachingTechniques in Applied Behavior Analysis

Reinforcement Systems Activity Schedules In vivo Modeling Video Modeling Script/Script Fading

Procedures Dyadic Instruction Small Group Instruction Self Management Direct Instruction

Incidental Teaching Computer Mediated

Instruction Peer Mediated Instruction Discrete Trial Instruction Fluency based Instruction Shaping and Chaining Task Analysis Functional Communication

Training

A Non-exhaustive List ofBehavior Reduction Techniques in ABA

Reinforcement Systemssuch as DRO, DRI, DRA

NoncontingentReinforcement

EnvironmentalAdaptations

Teaching Adaptations Curricular Modifications Functional

CommunicationTraining

Extinction Time Out Response Cost Other Negative Punishment

Procedures Contingent Task Overcorrection Other Positive Punishment

Procedures

ABA is just not about treating youngchildren with autism• Over the past 50 years, ABA has been shown to be

effective across a wide variety of- populations (children and adults with mental illness,

developmental disabilities and learning disorders,typically developing students)

- interventionists (parents, teachers, paraprofessionals,other staff, siblings, classmates)

- settings (schools, homes, institutions, group homes,hospitals and corporate settings), and

- behaviors (language; social, academic, leisure andfunctional life skills; aggression, self injury,stereotypical behaviors)

Empirical Literature Supporting ABA• The empirical literature supporting ABA is extensive

and continues to be amassed (several hundredarticles)

• This research can be categorized:• Treatment outcome data for specific skills• Treatment outcome data for longer term

interventions• Applications of specific practices (e.g., discrete

trial instruction, fluency based instruction,incidental teaching)

• Comparisons of 2 ABA techniques

Some Prior Reviews of Literature

• Hingtgen & Bryson (1972)

• DeMeyer, Hingtgen, & Jackson (1981)

• Matson, Benavidez, Compton, Paclawskyj, &Baglio (1996)



Some Peer Reviewed Published ResearchEarly Intervention Using ABA

Fenske, E.C., Zalenski, S., Krantz, P.J., & McClannahan, L.E.(1985).

Lovaas, O.I. (1987)Anderson, S.R., Avery, D.L., DiPietro, E.K., Edwards, G.L., &

Christian, W.P. (1987)Harris, S. L., Handleman, J. S., Gordon, R., Kristoff, B., & Fuentes,

F. (1991)Birnbrauer, J.S. & Leach, D.J. (1993)Sheinfopf, S. J., & Siegel, B. (1998)Weiss, M. J. (1999)McGee, G.G., Morrier, M.J., & Daly, T. (1999)Koegel, L.K., Koegel, R.L., Harrower, J.K. & Carter, C.M. (1999)(2005)

Some Peer Reviewed Published ResearchEarly Intervention Using ABA

Luiselli, Cannon, Ellis, & Sisson, (2000)Smith, T., Groen, A. D., & Wynn J. W. (2000)Green, Brennan, & Fein (2002)Eikeseth,S. Smith,T., Jahr,E. & Eldevik, S. (2002)Stahmer, A.C. & Ingersoll, B. (2004)Sallows and Graupner (2005)Cohen, Amerine-Dickens, & Eldevik (2002)Howard, J.S., Sparkman, C.R., Cohen, H.G., Green, G., Stanislaw,

H. (2005)

Research: Home-Based ABA Intervention• Specifically research for intervention delivered in

homes:– Anderson, Avery, DiPietro, Edwards, & Christian, 1987;– Birnbrauer, & Leach, 1993;– Green, Brennan, & Fein, 2002;– Lovaas, 1987;– Luiselli, Cannon, Ellis, & Sisson, 2000;– Sheinkopf, & Siegel, 1998;– Smith, Groen, & Wynn, 2000;– Weiss, 1999

• Moreover, many studies describing center-basedintervention delivery have incorporated somecomponent of intervention carried out in the home.

Research: Home-Based ABA Intervention

• Common elements:– Multitude of behavior analytic procedures– Intensive and long in duration– Provided effectively by experienced persons– Promotion of generalization

• Further research is needed:– To examine various levels of intensity, duration, and other

treatment parameters– To “unpack” treatment components and identify which lead

to best outcomes.– To systematically compare outcomes BETWEEN home-based

and center-based models …………….controlling for the arrayof variables that may confound the results


• Activity Schedules

• Direct Instruction

• Discrete Trial Instruction

• Early Behavioral Intervention/Treatment

• Functional Assessment/Analysis

• Functional Communication Training (FCT)


• Incidental Teaching

• Peer Mediated Social Skills Training

• Pivotal Response Training (PRT)/Natural LanguageParadigm

• Positive Behavioral Support

• Precision Teaching/Fluency-Based Instruction




• Self-Management

• UCLA/Lovaas Intervention

• Verbal Behavior/Applied Verbal Behavior

What were the Early TheoreticalPerspectives about Treatment Research?

For a number of reasons, it took several decadesbefore ABA emerged as a scientifically validatedtreatment for autism and related disorders.– ABA was not yet a visible treatment model– Psychodynamic treatment was in vogue– Parents were not considered part of a solution– Parents were not mobilized


When autism emerged as a clinical entity almostsixty years ago, the conceptualization andtreatment of pervasive developmental disordersspecifically, and all childhood psychopathologyin general, was essentially psychodynamic innature (Bettleheim, 1967; King, 1964; Mahler,1965).

Maternal rejection, apathy, and hostility werebelieved to be the cause of PDD (e.g.,"Refrigerator Mother" theory).


• For a few decades, thetreatment of autismwas dominated bypsychodynamictheory.

• With no evidencewhatsoever!

A Dark Cloudover AutismTreatment


Interventions included:– Play therapy to provide the child with an

emotional re-experiencing of the faulty parent-child relationship;

– Institutionalization so that the child could beremoved from a supposedly harsh homeenvironment; and

– Long term psychotherapy for the mother toaddress her underlying personalitydisturbance.

What Events Led to a Shifting inTheoretical Perspectives of PDD? B. F Skinner's extensive laboratory work inB. F Skinner's extensive laboratory work in

learning theory helped shape our currentlearning theory helped shape our currentunderstanding of how behavior can be modifiedunderstanding of how behavior can be modifiedby changes in the environment and through theby changes in the environment and through theuse of reinforcement procedures.use of reinforcement procedures.

Ferster and DeMyer's research (1961, 1962)Ferster and DeMyer's research (1961, 1962)demonstrated that the behavior of children withdemonstrated that the behavior of children withautism could be modified by changingautism could be modified by changingenvironmental consequences. This frameworkenvironmental consequences. This frameworkwas dramatically different from thewas dramatically different from thepsychodynamic model mentioned earlier.psychodynamic model mentioned earlier.



What Events Led to a Shifting inTheoretical Perspectives of PDD?

Ivar LovaasIvar Lovaas’’ preliminary research in the 1960 preliminary research in the 1960’’ssalso demonstrated that the behavior ofalso demonstrated that the behavior ofindividuals with autism can be dramaticallyindividuals with autism can be dramaticallyimproved by the modification of antecedents andimproved by the modification of antecedents andconsequences (e.g., Lovaas, 1969; Lovaas,consequences (e.g., Lovaas, 1969; Lovaas,Berberich, Perloff, & Schaeffer, 1966; Lovaas &Berberich, Perloff, & Schaeffer, 1966; Lovaas &Simmons, 1969).Simmons, 1969).

His contributions have lead to him being referredHis contributions have lead to him being referredto as the to as the ““one of the greatest pioneersone of the greatest pioneers”” in the in thebehavioral treatment of Autism Spectrumbehavioral treatment of Autism SpectrumDisorders.Disorders.


It is important to note that the early behaviorallyoriented researchers were scorned by membersof the professional community who remainedlargely psychodynamic in orientation.

Early criticisms were widespread and many ofthese still exist today (e.g., ABA is all aboutpunishment, ABA turns children into robots,there is NO generalization, symptom substitutionwill emerge).

What Events Led to a Shifting inTheoretical Perspectives of PDD? Over the years, ABA treatment has became more

widely accepted and today, represent the onlyintervention approach for autism supported byextensive empirical research (500+ articles).

The 1970’s and early 1980’s also witnessed researchdocumenting no differences between parents ofchildren with autism and parents of normallydeveloping children (e.g., Cantwell, Baker, & Rutter,1979; DeMyer, Hingtgen, & Jackson, 1981; Koegel,Schreibman, O’Neill, & Burke, 1983; McAdoo &DeMyer, 1979; Wolchik, 1983).


The subsequent accumulation of neuro-chemical,neuro-anatomical, and genetic data have supported abiological or medical cause for PDD. However, theremay be multiple pathways that give rise to the variousPDD’s - some genetic in nature, others not.

Although the specific cause of PDD is not known, thereis a growing support for the notion that the etiology (orcause) is biological and multi-causal in nature thancaused by a single agent

Where Have We Been?• Seen the professional community refrain from the

“blanket blaming” of parents

• Witnessed an accumulating amount of empiricallyvalidated research demonstrating ABA efficacy

• But took a “Publish and Hope” approach

• Observed somewhat limited– Dissemination of the technology– Applications within the public sector– Accurate media attention– Interest in ABA

Where Have We Been?• Seen that the “explicit” demand for ABA services

had not necessarily exceeded supply of providers(in contras to today)



Where Have We Been?

• University-based and center-based educationalprograms had achieved substantial evolution ofservices……but somewhat in an isolated manner

• Observed marked discrepancies between quality ofservices received by learners in center-basedprograms versus most other programs

• Children of minorities, from low SES groups, andfrom rural areas were significantly underserved

Where Are We NOW?

• As we have discussedd, ABA is receiving anincreasing number of endorsements by state andfederal agencies.

• Multidisciplinary, independent reviews ofresearch on a wide array of autism treatmentsusing an evidence based approach have beenconducted by a few states task forces.

• Please note that these endorsementsacknowledge an EXISTING body of scientificsupport.

Where Are We Now?

• We are seeing an increasing number of identifiedindividuals with autism

• The gap between supply and demand is WIDERthen ever.

• ……..And many parents report being placed onwaiting lists for services.

Where Are We NOW?• University-based graduate training programs are

recruiting and training the next generation ofBehavior Analysts

– Go to www.abainternational.org for moreinformation

• A certification process in applied behavior analysishas been established

– Go to www.bacb.com for more information

• Consumers can visit that site to peruse a directoryof certified individuals.

Where Are We Now?• Many aspects of Behavior Analyst Certification Board

Guidelines for Responsible Conduct For BehaviorAnalysts© bear relevance to our topic:– 1.01 Reliance on Scientific Knowledge– 2.09 Treatment Efficacy– 5.01 Designing Competent Training Programs– 8.02 Disseminating Behavior Analysis– 10.01 Promotion in Society– 10.02 Scientific Inquiry

Where Are We Now?• Certification in behavior analysis has not been around

long enough to guide consumers in separating thepotentially qualified from the possibly non-qualified.

• Furthermore, consumers must recognize thatcertification in behavior analysis does NOT mean thatthe provider possesses competence in the delivery ofbehavior analytic service to persons with autism or isable to oversee programming.



Revised Guidelines for Consumers ofABA Services to Individualswith Autism and Related Disorders

• The Autism SIG has undertaken the complex, yetcritical, task of providing consumers with someguidance regarding how to select a behavior analyticservice provider.

• The current version of guidelines can be found athttp://www.autismsig.org ORhttp://abainternational.org/Special_Interests/autism_guidelines.asp

Revised Guidelines for Consumers ofABA Services to Individualswith Autism and Related Disorders

Section I: Certification by BACB or documentedevidence of equivalent education, professionaltraining, and supervised experience in appliedbehavior analysis

Section IIa: One FULL calendar year of hands ontraining

Section IIb: Additional training in directing andsupervising ABA programs

Where Are We Now?

• The literature supporting the use of ABA isexpanded and enhanced each year.

• We are in an era where the prognosis for a higherquality of life is possible for most persons withautism ACROSS the lifespan.

Where Are We Now?

• Growing commitment to evidence-based practice– No Child Left Behind– American Psychiatric Association– Association for Behavioral and Cognitive Therapies

(www.aabt.org)– Cochrane Organization (www.cochrane.org)– Campbell Collaboration (www.campbellcollaboration.org)– Division of Early Childhood for CEC– American Speech-Language-Hearing Association (ASHA)– American Psychological Association, Division 12, 1993

Task Force– American Psychological Association 2005 Policy

Statement on Evidence-Based Practice in Psychology– http://www.apa.org/practice/ebp.html

Where Are We Now?

• APA Division 12 criteria for “Well EstablishedTreatment”– At least two good group designs conducted by different

investigators– OR, a large series of single case designs

• APA Division 12 criteria for “Probably EfficaciousTreatments”– At least two good group designs conducted by same

investigator or one good study– OR, a small series of single case designs

Where Are We Now?

• Criteria are far from perfect though, particularlygiven the abundance of single case research inautism treatment.



Where Are We Now?

• Despite the broad base of published research,many important questions remain.

• Techniques within the discipline of ABA that areperceived to be “new” are proposed each year.

Where Should We Be Going?

• Expectations that treatment proponentsshould put “their data were their mouth is.”

• Ongoing research that helps us make betterchoices among procedures

•• Development of packages involving a broader

spectrum of scientifically verified techniques

• More responsible journalism


• Having data-based or collaboratively generatedguidelines about which individuals

for which topographies of responsesand under which conditions would likely benefitfrom which procedures and when


• Acknowledging scientific advances of otherdisciplines

• …..In some cases, this may involveacknowledging that other disciplines arecapable of scientific research

• Incorporating these advances into treatmentpackages to create synergistic gains

• ……….and/or making appropriate referrals

As New Treatment Research is Published?

• As research from other disciplines emerge,providers have choices

Embrace Blindly or Evaluate Critically

• As research from other disciplines emerge,behavior analysts have choices

Evaluate Critically or Disregard Altogether……and Perhaps also reinforce gradual

approximations

Where Can Professionals Go From Here?

• We should appreciate parents’ perspectives andrecognize our duty to empower and educate.

• We should provide parents with tools toenhance chances of making the most objectiveand informed decisions.

• We should help consumers draw upon thescientific rigor of ABA when evaluating efficacyof any and all interventions.



Where Can Professionals Go From Here?

• It can not be overstated that children with autismreceiving intervention are entitled to an objectiveassessment of that intervention

• Looking to the future, the treatment options will beclearer for parents, teachers, and other consumersIF:– There is a shared commitment to science– There is mutual respect across disciplines– Providers are up front about the research basis to

the interventions that they are suggesting– Data guide decision making, data settle debates– Consumers ask the tough questions and demand

answers

Where Should We Be Going?• Helping more individuals garner access to state

of the art intervention, regardless if they are• “Over age 6”• Of minority descent• From less affluent families• From rural areas• From districts with limited resources

• Ensuring that parents do not have to fight sohard when advocating for their children

• Meeting the needs of adults with autism andpublishing more research in that area

Where Should We Be Going?• Achieving greater unification within field of ABA• Embracing our shared values:

• commitment to best interest of consumers• recognition of parents as partners• commitment to individualized intervention• explicitly stated procedures• ongoing assessment• commitment to within subject design/idiographic

data• objective verification of efficacy• data-based decision making• advancement of science


• Acknowledging scientific advances of otherdisciplines

• …..Better yet, acknowledging that other disciplinesare capable of scientific research

• Incorporating these advances into treatmentpackages to create synergistic gains

• ……….and/or making appropriate referrals

ABA Practices that haveImplications for Other Interventions

• Identify targets for change• Operationalize your targets (specific,

observable)• Operationalize your intervention• Obtain adequate baseline data• Repeated measurements by collecting data

on ongoing basis

ABA Practices that haveImplications for Other Interventions

• Collect IOA data• Evaluate treatment fidelity• Observe trends in data to evaluate

effectiveness• Maintain, alter, or discontinue intervention

based upon objective information• Change treatments one at a time to maximize

accuracy of decisions evaluating thosechanges



A Few Considerations about Baseline

• Baseline represents the current frequency/level ofthe behavior.

• Baseline is intended to represent “pre-intervention”status (i.e., the period prior to the new intervention).

• The baseline period does not necessarily imply thatthere is a total lack of intervention during thatperiod.

• Baseline data enable one to compare student tohimself/herself rather than to a group of similarindividuals. (idiographic data).

• It may be determined that no intervention isneeded.

A Few Considerations about Baseline• Data collection need not be exhaustive to be

meaningful, particularly if time sampling is wellthought out. Exhaustive data collection may becumbersome or overwhelming and may lead toinaccurate or fabricated data.

• If the behavioral intervention will be implemented inboth home and school settings or if generalizationwill be assessed, then baseline data should becollected in both settings.

A Few Considerations about Baseline• The length of baseline will vary from case to case.• Baseline should include enough data points to

show: 1) stability (minimal variability across thedata points); or 2) an ascending trend (data appearto be accelerating),

Baseline can involve as few as 3 data points (ifstability is present).

– 14,13,14– 45,40,44,42– 29, 29, 29….ok, ok…I know this never happens


• Trends in the desired direction (i.e., decline) maysuggest that the target behavior is improving andthat an intervention may not be necessary after all.

– 42, 44, 30, 25– 89, 50, 44, 38– 87%, 68%, 60%, 56%

• Extremely variable data will warrant an extendedbaseline.

– 42, 70, 25– 42, 60, 5, 48– 37%, 68%, 14%– 79%, 40%, 42%, 68%

• If a target behavior occurs in limited situations withrelatively stable frequencies (i.e., little variability indata), a briefer baseline period will be needed toestablish reliable estimates of the target behavior.

• Conversely, when behavior rates are low, variable,and/or when events occasioning the targetbehaviors vary substantially over either time oracross settings, then the minimum amount ofbaseline required to achieve stability is less certain.


Common ABA Practices that haveImplications for Other Interventions

• Employ a variety of single case researchdesigns:– To test hypotheses– To identify functional relationships between IV

manipulation and DV– To assess effect

• Commonly employed designs:– AB Design– ABA Reversal Design– ABAB Repeated Reversal Design– Multiple Baseline Design– Simultaneous or Alternating Treatments Design– Changing Criterion Design



Common ABA Practices that haveImplications for Other Interventions

• Visual Inspection of Data to Note:– Latency for change to be observed– Heterogeneity of data– Trends and levels– Overlapping data across conditions– Similarity in data display across conditions

• See:– Horner, Carr, Halle, McGee, Odom, & Wolery

(2005)– Kazdin (1992)– Kratochwill & Levin (1992)– Parsonson & Baer (1978)

Concerns that HaveImplications for Other Interventions

• Threats to Internal Validity (See Cook &Campbell, 1979)– History– Maturation– Testing– Instrumentation– Statistical regression– Selection biases– Attrition– Combinations of selection and other threats)

Concerns that HaveImplications for Other Interventions

• Threats to External Validity (See Cook &Campbell, 1979)– Sample characteristics– Stimulus characteristics– Contextual characteristics– Assessment characteristics

• Social validity– Treatments– Goals– Outcomes

Group Designs• Pre Test/ Post Test• Pre Test/ Post Test with a Control Group• Counterbalanced Group Design• Between Subjects Group Design

Key Characteristics ofScientific Research

• Scientific Method—A hypothesis about what works,or how it works, is formulated and tested using aresearch design.

• Replicated—Several studies find the SAME result.

• Generalizable—Study findings can be appliedbroadly, to individuals other than the ones studied.

Key Characteristics ofScientific Research

• Meets Rigorous Standards—The study's design,measures, and interpretation of results meet rigorousstandards of peer review.

• Convergent findings—Results found using differentapproaches all point to the same conclusion.



Other Characteristics ofScientific Research

• States findings tentatively

• Avoids confusing correlation with causation

• Avoids sweeping overgeneralizations

• One published study does not warrant a paradigmshift

Objective Assessment and Data CollectionWhy is this Essential?

• Individuals with autism deserve prompt andeffective assessment, analysis, andtroubleshooting.

• We must be accountable to other consumersas well.

Objective Assessment and Data CollectionWhy is this Essential?

• ALL skill acquisition and behavioral reductionefforts need to be evaluated throughsystematic review of data.

• …..This includes medication trials, sensorydiets, prism glasses, and restricted diets!

Objective Assessment and Data CollectionHow can this be implemented?

• The National Research Council recommendsONGOING assessment of treatmentobjectives to assess degree of benefit.

• Supervisors /consultants should educate theinvolved parties so that they understand theimportance and role of data.


• Behaviors targeted for change are objectivelydefined and made explicit

• Challenging behaviors are operationallydefined to promote more reliable and validmeasurement.


• Data should be collected for all interventionsand reviewed regularly.

• Local providers should be trained/educatedabout data collection.

• Their data collection efforts should bemonitored/reinforced.




• Data collection for behaviors targeted foracceleration may include:– percentage of correct trials– rate of responding– percentage of opportunities in which desired

response occurred– percentage of intervals in which desired behavior

occurred– number and types of prompts needed– permanent products– cumulative record of mastered responses


• Data collection for behaviors targeted fordeceleration may include:– Rate/frequency– Duration– Intensity– Latency– Percentage of intervals in which undesired

behavior occurred– Percentage of opportunities in which undesired

response occurred


• The worst kind of data to collect is data thatare ignored.

• Data should guide decision making and betranslated into adjustments in how theintervention is carried out.

• The benefits of these adjustments should beevaluated.


• The National Research Council recommends

“that a lack of objective, documentableprogress over a 3 month period should betaken to indicate a need to increase intensityby lower student teacher ratios, increasingprogramming time, reformulating curricula, orproviding additional training and consultation”-page 221


• Any provider offering any intervention shouldcollect data to document and measureefficacy.

• When appropriate, parents also collect data.


• Reasonable expectations are made about theamount of data collection and clear rationalesfor the need for data are provided.

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