Evaluating Treatments for Children with Autism

Ed553Applied Behavior Analysis Programs

Caldwell College

Science and Assessing Effective Treatment

Science provides certain criteria to decide what information is, and is not, valid (accurate)

Certain characteristics can be seen in “treatments” that are likely NOT scientifically validated

In this presentation, we will use the terms TREATMENT, THERAPY, and INTERVENTION interchangeably

How do I Evaluate Treatment Claims?Psuedoscientific Therapies: Some Warning Signs*originally printed in Science in Autism Treatment, Spring

1999. High "success" claimed without valid

supporting evidence Rapid effects promised Therapy said to be effective for many

symptoms or disorders without evidence that you can generalize these effects

“Theory” behind the therapy contradicts objective knowledge (and, sometimes, common sense)

Therapy said to be easy to administer, requiring little training or expertise

How do I Evaluate Treatment Claims?

Other currently validated treatments are said to be unnecessary, inferior, or harmful.

Promoters of the therapy work outside their area of expertise.

Only testimonials, anecdotes, or personal accounts are offered in support of claims about the therapy's effectiveness. Little or no objective evidence is provided.

Catchy, emotionally appealing slogans are used in marketing the therapy.

Belief and faith are said to be necessary for the therapy to "work."

How do I Evaluate Treatment Claims?

Skepticism and critical evaluation are said to make the therapy's effects evaporate.

Promoters resist objective evaluation and scrutiny of the therapy by others.

Negative findings from scientific studies are ignored or dismissed.

Critics and scientific investigators are often met with hostility, and are accused of persecuting the promoters, being "close-minded," or having some ulterior motive for "debunking" the therapy.

More…How do I Evaluate Treatment Claims?

Source: American Academy of Pediatrics Committee on Children with Disabilities

Treatment is based on overly simplified scientific theories (e. g., “certain sounds can re-organize the brain”)

Treatment fails to identify specific treatment objectives or target behaviors

Treatments are stated to have no adverse effects without supporting evidence; thus, proponents deny the need to conduct controlled studies– (This contradicts ALL ethical codes, which require

“First, do no harm!”)

Sensory Integration Therapy

Sensory Integration (SI) therapy is a sensory-motor treatment developed by Dr. A. Jean Ayres.

Proponents theorize that sensory integration is an innate neurobiological process (Hatch-Rasmussen, 1995), and that children with autism and other developmental delays experience dysfunction in which sensory input is not “integrated” or organized appropriately by the brain.

Evaluating Sensory Integration Therapy

Current research does not support SI as an effective treatment for children with autism, developmental delays or mental retardation

SI has not been shown to be responsible for positive change in a child's behaviors or skills.

In at least one study, SI was shown to actually increase self-injurious behaviors.

Association for Science in Autism Treatment

Evaluating Sensory Integration Therapy

"Though Sensory Integration Therapy does not appear to enhance language, control disruptive behaviors, or otherwise reduce autistic behaviors, it may offer enjoyable, healthy physical activity (Smith, 1996).”

“Professionals considering SI interventions should portray the intervention as experimental, and disclose this status to key decision makers influencing the child's intervention.”

Association for Science in Autism Treatment

Auditory Integration Training Developed in 1960s by French physician Guy

Berard AIT is based on unproven theory that symptoms in

autism are caused by auditory perception defects that distort sound or produce auditory hypersensitivity (hyperacusis).

Treatment consists of identification of sound

distortion or hypersensitivity followed by twice daily sessions for 2 weeks in which computer modified music determined to be optimum for the patient is played through a device called the Audiokinetron.

Concerns

Audiokinetron may potentially be unsafe, delivering levels of sound to the eardrum that may be harmful to hearing.

AIT devices do not have FDA approval for treating autism or any other medical problem.

The FDA has banned the importation of the Electric Ear and any other AIT device made by Tomatis International, of Paris, France.

Evaluating Auditory Integration Therapy

No well-designed scientific studies demonstrate that AIT is useful (in any form including Tomatis®); therefore AIT is not recommended for children with autism.

The American Academy of Pediatrics The American Academy of Audiology

Evaluating Auditory Integration Therapy

AIT is not yet objectively substantiated as effective subject to the rigors of good science.

Professionals considering AIT should portray the method as experimental, and should disclose this status to key decision makers influencing the child's intervention.

Association for Science in Autism Treatment

Evaluating Auditory Integration Therapy A randomized controlled trial with an adequate sample

size found no differences in children receiving auditory integration training as compared with those listening to the same music which had not been modified.

A recent controlled study found no benefit of AIT and poorer scores on social and adaptive and expressive language scores after AIT.

“Because of the lack of demonstrated efficacy and the expense of the intervention, it is recommended that auditory integration training not be used as an intervention for young children with autism.”

New York State Department of Health Early Intervention Guidelines

Claims of Evidence for AIT Two studies are offered by AIT proponents which do not meet

the rigors of scientifically valid research: Gilmor, T. M. (1999). The Efficacy of the Tomatis method for

Children with Learning and Communication Disorders, International Journal of Listening, 13, 12. – This journal does not fit the definition of “peer reviewed”

(review by published scientists)– Conclusions in the paper are based on the technique of meta-

analysis of past studies (conclusions drawn from selected pieces of many studies) not empirically validated research.

Credibility of Journal’s mother organization (International Listening Association) is questionable. Web page contains quotes from Artists, Writers, and Rock Stars– "Listen, learn, read” from Deep Purple

Claims of Evidence for AIT Second study offered by AIT proponents:

– Neysmith-Roy,  J.  M. (2001). The Tomatis Method with severely autistic boys: Individual case studies of behavioral changes, South African Journal of Psychology, 31.

– Case study does not qualify as empirically validated research. It is a description of somebody’s characteristics but has no controlled assessment of treatment variables.

Traditional Speech & Language Therapies Non-behavioral speech and language

therapists have developed many different treatments (e.g., PROMPT) most of which are aimed at stimulating children’s natural interest and ability in learning language.

The treatments usually take place in one-to-one sessions held from ½ to 3 hrs per week.

Evidence of Traditional Speech & Language Therapies No scientific studies have evaluated whether any

form of speech and language therapy, other than behavior analysis, helps children with autism.

There have been no studies to evaluate the effectiveness of PROMPT therapy with children with autism – Dr. Rogers at the MIND Institute is currently heading

up a project comparing PROMPT with other models of language

– No outcome data have been produced, as of yet.

Evaluating Traditional Speech & Language Therapies By itself, speech and language therapy is

probably not intensive enough to be very effective.

However, it may augment other interventions by identifying areas that need remediation or offering strategies for promoting the use of language skills in everyday settings.

Speech & Language Therapies Using ABA

A variety of behavioral techniques has been shown to be effective for increasing and improving language and communication in children with autism (e.g., activity schedules, audio modeling, video modeling, PECS)

When teaching children with autism, speech and language therapy has been shown to be maximally effective when delivered using the principles of ABA

What is an “Integrated” Treatment Model”?

(Sometimes referred to as combination model, comprehensive model, eclectic model, whole person model)

Using an “integrated” model assumes there are multiple effective therapies that, when combined, work even better than the single effective therapies.

Using an “integrated model” also assumes that proponents are using only the therapies that have been shown to work while ignoring the ones that have not.

But to find out which ones work, you MUST look for controlled studies that demonstrate effectiveness (use objective data, not testimony).

If this has not been done, then proponents may be taking away time from therapies that have been shown to be effective by advocating for an integrated model

There is currently NO evidence that combinations of therapies for autism are better than the sum of their parts.

Evaluation of Integrated Therapies Eikeseth, Smith, Jahr, & Eldevik (2002)

– Compared applied behavior analysis (ABA) with an integrated treatment

– ABA treatment consisted of language, social, academic, fine/gross motor, and self-help skills

– Integrated treatment consisted of: sensory integration therapy, speech therapy, and ABA

– At a 1-year evaluation, 13 children who had received ABA treatment made significantly larger improvements than a comparison group of 12 children who had receive intensive, integrated therapy.

– On average the ABA group gained 17 points in IQ, 13 points in language comprehension, 23 points in expressive language, and 11 points in adaptive behavior.

Greenspan (DIR; Floortime) Stanley Greenspan, MD and colleagues have

published papers on theories of child development. Only one relates specifically to children with autism;

others may include references to autism among an array of disabilities.

Greenspan and others have created a “developmental approach” for early intervention with children with disabilities (Developmental Individual-Difference, Relationship-Based Model) commonly referred to as the "Floor Time" approach (Greenspan, 1998).

Greenspan (DIR; Floortime) DIR/Floor Time includes interactive

experiences, which are child-directed, in a low stimulus environment, ranging from two to five hours a day.

During a preschool program, DIR/Floor Time includes integration with typically-developing peers.

Greenspan contends that interactive play, in which the adult follows the child's lead, will encourage the child to "want" to relate to the outside world. (Greenspan, 1998).

Evaluating Greenspan therapy

“There have been no peer-reviewed, published studies of Greenspan's DIR/Floor Time's effectiveness for children with autism. Professionals considering Greenspan's Floor Time should portray the method as without peer-reviewed scientific evaluation, and should disclose this status to key decision makers influencing the child's intervention.”

Association for Science in Autism Treatment

Evaluating Greenspan therapy

“There are no adequate controlled trials that have evaluated the efficacy of intervention approaches based on the DIR model for treating young children with autism”

“Approaches based on the DIR model can be time intensive for both professionals and parents and may take time away from other therapies that have been demonstrated to be effective”

New York State Department of Health Early Intervention Guidelines

Miller Method

The Miller Method™ uses adaptive equipment, including platforms (that elevate the child in hopes of increasing eye contact), large swinging balls (to expand the child's reality system), and Swiss cheese boards (to teach motor planning, as well as to increase the child's understanding of his or her relation to environment and space.) (Miller, 1998).

Evaluation of Miller Method

The Miller Method™ may have promise, but it is not yet objectively substantiated as effective subject to the rigors of good science.

Professionals considering the Miller Method™ should portray the method as experimental, and should disclose this status to key decision makers influencing the child's intervention. Association for Science in Autism Treatment

Nutritional Supplements and Megavitamin Therapy Anecdotal and case reports have generated

interest in the use of a variety of nutritional

supplements to treat children with ASD. Studies have shown mixed results Some studies have been criticized for their

methodological shortcomings and failure to address the issue of safety of use.

Elimination diets

The presence of allergies or food intolerance in children often stimulates families to explore unconventional diets.

Recent investigations failed to document a higher prevalence of hypersensitivity to common food allergens in children with autism compared with controls.

Immune Globulin therapy

There is some evidence for immunologic abnormalities

in small numbers of children with autism including abnormalities of T cells, B cells, natural killer cells, and the complement system

In a study of 20 children with ASD, 10 who received intravenous immune globulin for a 6-month period reportedly demonstrated improvements in social behavior, eye contact, echolalia, and speech articulation.

Note: The investigators did not use standard outcome measures and did not state whether participants received other concurrent treatments during the course of the study.

Immune Globulin therapy

• Two recent reports failed to demonstrate significant changes in behaviors associated with autism in 17 children who received regular infusions of immune globulin for a 6-month period.

• There is no scientific evidence to justify the use of infusions of immune globulin to treat children with autism.

Secretin

Anecdotal reports of 3 children whose behaviors were seemingly helped by secretin generated much publicity and interest in its treatment potential

Recent studies, however, have failed to demonstrate any scientific evidence to justify the use of secretin infusion to treat children with autism.

Chelation Therapy

Some theorize that autism might be caused by early childhood exposure to environmental

toxicants, particularly mercury To date, there are no published studies linking

mercury exposure to the development of autism or demonstrating that children with autism have had greater exposure to mercury than have unaffected children.

Evaluating Chelation Therapy Although several chelating agents have

been shown to accelerate mercury elimination from the body, there is no evidence that chelation therapy will improve developmental function.

Moreover, chelating agents can have significant toxicity and cause allergic reaction.

Chelation therapy is therefore not recommended to treat autism

Applied Behavior Analysis(Behavior Management; Intensive Behavioral Intervention)

“Intensive, behavioral intervention early in life can increase the ability of the child with autism to acquire language and ability to learn.”

“Thirty years of research demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior. A well-designed study of a psychosocial intervention was carried out by Lovaas and colleagues (Lovaas, 1987; McEachin et al., 1993). Up to this point, a number of other research groups have provided at least a partial replication of the Lovaas model (see Rogers, 1998).”

U.S. Surgeon General David Satcher, M.D., Ph.D.

Applied Behavior Analysis “All programs educating children with autism

should include intensive behavioral interventions and year-round education”.

The US Dept. of Education and the National Research Council's Report

'Educating Children with Autism ‘ “Since intensive behavioral programs appear to be

effective in young children with autism, it is recommended that principles of applied behavior analysis and behavioral intervention strategies be included as an important element of any intervention program”.

NYS Department of Health Early Intervention: Clinical Practice Guidelines:

References American Academy of Pediatrics Committee on

Children With Disabilities. (2001). Technical Report: The Pediatrician's Role in the Diagnosis and Management of Autistic Spectrum Disorder in Children, Pediatrics, 107(5).

Fenske, E. C., Zalenski, S., Krantz, P. J., & McClannahan, L. E. (1985). Age of intervention and treatment outcome for autistic children in a comprehensive intervention program. Analysis and Intervention in Developmental Disabilities, 5, 49-58.

References Jacobson, J. W. (2001). Early intensive behavioral

intervention: Emergence of a consumer-driven service model. The Behavior Analyst, 23(2), 149-171.

McEachin, J. J, Smith, T., & Lovaas, O. I. (1993). Long term outcome for children with autism who received early intensive behavioral treatment. American Journal on Mental Retardation, 97(4), 359-372.

Smith, T. (1993). Autism. In T. Giles (Ed.), Handbook of effective psychotherapy (pp. 107-133). NY: Plenum Press.

ABA Resources

• Books– Handleman, J. S., & Harris, S. L. (2001). Preschool

education programs for children with autism. Austin, TX: Pro-Ed.

– Harris, S. L., & Weiss, M. J., (1998). Right from the start: Behavioral intervention for young children with autism. Bethesda, MD: Woodbine House.

– McClannahan, L. E., & Krantz, P. J. (1999). Activity schedules for children with autism: Teaching independent behavior. Bethesda, MD: Woodbine House.

ABA Resources

• Books– Leaf, R., & McEachin, J. (Eds.). (1999). A work in progress:

Behavior management strategies and a curriculum for intensive behavioral treatment of autism. New York: DRL Books.

– Lovaas, O. I. (2002). Teaching individuals with developmental delays: Basic intervention techniques. Austin, TX: Pro-Ed.

– Maurice, C., Green, G., & Fox, R. M. (Eds.). (2001). Making a difference: Behavioral intervention for autism. Austin, TX: Pro-Ed.

– Maurice, C., Green, G., & Luce, S. C. (Eds.). (1996). Behavioral intervention for young children with autism. Austin, TX: Pro-Ed.

ABA Resources

Websites

– NY State Guidelines• www.health.state.ny.us/nysdoh/eip/autism/autism.htm

- Behavior Analysis Certification Board• www.bacb.com

- General Information about Autism• www.asatonline.org/autism_info.html

• www.behavior.org/autism/

• pediatrics.aappublications.org/cgi/reprint/107/5/e85.pdf

• books.nap.edu/books/0309072697/html/index.html