Autism is empirically validated treatment
I am writing this essay in order to evaluate critically, the claim that early intensive behavioral intervention for autism is an empirically validated treatment. I will try to illustrate my answer based on different studies and applications of early intensive behavioral intervention for autism and figure out its effectiveness.
According to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR, 2000), autistic disorder belongs in the category of the pervasive developmental disorders, and by definition, its onset is prior to age 3 years. The diagnostic criteria as placed in DSM-IV are: A. A total six (or more) items from 1, 2, 3, with at least two from 1, and one each from 2 and 3: 1) qualitative impairment in social interaction, as manifested by at least two of the following: (a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction, (b) failure to develop peer relationships appropriate to developmental level, (c) a lack of spontaneous seeking to share enjoyment, interests or achievements with other people, (d) lack of social or emotional reciprocity. 2) qualitative impairments in communication as manifested by at least one of the following: (a) delay in, or total lack of, the development of spoken language, (b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others, (c) stereotyped and repetitive use of language or idiosyncratic language, (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level. 3) restricted repetitive and stereotyped patterns of behavior, interests and activities as manifested by at least one of the following: (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus, (b) apparently inflexible adherence to specific, nonfunctional routines or rituals, (c) stereotyped and repetitive motor mannerisms, (d) persistent preoccupation with parts of objects.
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: 1) social interaction, 2) language as used in social communication, or 3) symbolic or imaginative play. C. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.
Autistic disorder is among the most disabling form of psychopathology (Klinger & Dawson, 1996). After many years of finding that children with autism made only small or temporary improvements in treatment, investigators in the mid 1980s began to report substantial success with some early behavioral intervention programs (Smith, T., 1999). Behavior analytic treatment emphasizes the use of principles derived from research on operant conditioning. Therapists simplify children's environments to maximize successes and minimize failures; shaping, chaining and discrete trial training can be used in such treatments.
Behavior analytic treatment also emphasizes the use of functional analysis. In such analysis, therapists monitor the immediate antecedents and consequences of behaviors, so that they can determine how they may alter these antecedents and consequences to improve children's skills. In order to maintain children's motivation, therapists may assess how much interest children display for various different reinforcers and select those that seem especially attractive. To reduce disruptive behaviors, therapists may identify antecedents that appear to trigger the behaviors and consequences that appear to reward the behaviors, so that these antecedents and consequences can be altered (Smith, T., 1999).
Ivar Lovaas (1987), presented a study reporting a behavioral-intervention project -known as UCLA model- that sought to maximize behavioral treatment gains by treating autistic children during most of their waking hours for many years. Treatment included all significant persons in all significant environments. In addition, the project focused on very young autistic children (below the age of 4) because it was assumed that younger children would be less likely to discriminate between environments and therefore, more likely to generalize and to maintain their treatment gains.
Subjects were assigned to one of two groups: an intensive-treatment experimental group (n=19) that received more than 40 hours of one-to-one treatment per week, the minimal treatment Control Group 1 (n=19) that received 10 hours or less of one-to-one treatment per week and Control Group 2 that did not receive any behavioral intervention. Both treatment groups received treatment for two or more years. The results showed that in pretreatment measures there were no significant differences between the intensively treated experimental group and the minimally treated control groups. At follow-up, experimental group subjects did significantly better than control group subjects.
Specifically, he compared the educational and cognitive outcomes in the three groups. Follow-up data from an intensive, long-term experimental treatment group showed that 47% achieved normal intellectual and educational functioning, with normal-range IQ scores and successful first grade performance in public schools. Another 40% were mildly retarded and assigned to special classes for the language delayed, and only 10% were profoundly retarded and assigned to classes for the autistic/retarded. In the control groups, only 2% of the children achieved similarly positive outcomes. In general, the children who obtained the best outcomes were reported to maintain their gains up to 5 years after treatment (McEachin, Smith, & Lovaas, 1993).
Butter E., Mulick J. and Metz B. (2006), studied eight cases of learning recovery in children that had been previously diagnosed with an autistic spectrum disorder and mental retardation after early intervention. At the time of the study, the children ranged in age from 4 years, 2 months to 8 years, 8 months. The children were enrolled in an early intensive behavioral intervention (EIBI) program for 2,8 years and all children were not currently receiving EIBI services. Early intensive behavioral intervention services had been provided for 40 hours per week for three of the children, 20-30 hours per week for three children, and 10-20 hours per week for two children.
The results showed that the children presented in this study, achieved at least a 20-point gain in IQ over a 3-4 year period after early intensive behavioral intervention for autism and, the average gain in adaptive behavior standard scores was 43 points. Nonverbal IQ standard scores and academic achievement standard scores ended within the average range. Despite the overall gain in IQ, language skills were still below average for most children. The current study supports findings of other researchers that learning recovery in autism and pervasive developmental disorders is possible and may be related to intensive behavioral treatment.
In the study of Jones E., Feeley K. & Takacs J. (2007), a multiple probe design across responses was used to demonstrate the effectiveness of intensive intervention in establishing spontaneous verbal responses to 2 3-year-old children with autism. Intervention involved discrete-trial instruction, specific prompts, and error correction. Spontaneous responses were defined as specific verbal utterances following discriminative stimuli that did not involve explicit vocal directives.
The results of this study demonstrated that, even very young children with autism can be systematically taught to not only respond to nonvocal stimuli, but to demonstrate generalized performance of spontaneous responses, suggesting the importance of this type of intervention. In many instances, early intensive behavioral intervention programs rely heavily on vocal stimuli in teaching communicative responses.
On the other hand, the effects of low-intensity behavioral treatment for children with autism and mental retardation were studied by Eldevik S., Eikseth S., Jahr E. and Smith T. (2006). The behavioral treatment was based on UCLA model and children in this group received low-intensity one-to-one treatment. In addition, electric treatment was used; for children in this group elements from various types of treatment were combined in an attempt to best meet each child's educational needs.
Two groups of children were compared receiving either behavioral treatment or electric treatment (n=13, n=15 retrospectively), and the groups did not differ significantly at pretreatment. All children had been assessed at intake and after two years of treatment. They were assessed in intellectual and language functioning, adaptive behavior, non-verbal intelligence, pathology data and degree of mental retardation. The outcome data after 2 years of treatment showed that the behavioral group made significantly larger gains in most areas in comparison to the electric group. However, the gains were small and of questionable clinical significance than those reported with children that received more intensive behavioral treatment.
Most research studies in intensive behavioral treatment cited so far, have been conducted from specialist centers and clinics, where the treatment was provided by professionals and experts in applied behavior analysis and young children with autism (Bibby, Eikeseth, Martin, Mudford, Reeves, 2001).Bibby et al. (2001), presented a study investigating the effects of parent-initiated approximations to the UCLA workshop model. They conducted this study to assess whether parent-managed intensive behavioral intervention reproduced Lovaas's clinic-based results, to measure the progress of the children that received parent-managed intensive behavioral intervention, and to determine variables that may predict children's progress and outcomes.
The participants were 66 children (11 girls and 55 boys). Cognitive development, language skills, adaptive behavior, ratings of behavior were measured; additional data from interviews with parents were taken, as well as treatment personnel (parents were asked about program consultancy), and supplementary treatments (the interview with parents included discussion of supplementary treatments that the child had received during the previous 12 months). The results showed that mean IQ scores for 22 children did not change significantly, maintaining around the borderline of mild/moderate mental retardation. No significant improvement in standard or ratio scores in the areas of intellectual functioning, adaptive functioning or language was found. This study showed that the parent-managed model was insufficient and did not reproduce results from clinic-based professionally directed programs.
Apart from researches and studies that provide evidence that early intensive behavioral treatment is effective in autistic children, there are also studies that doubt the positive effects of this intervention. Boyd and Corley (2001), conducted a including 316 children with autism. Early intensive behavioral intervention services were decided to be provided in 22 children with a primary diagnosis of autism. The services were two years of 30-40 hours of discrete trials training per week in the home and a third year of 10 hours if the child had demonstrated reasonable progress.
The most important variable was whether the child had a recovery from autism and it was measured with normal IQ, replacement in regular education and a judgment that the child was indistinguishable from their normal friends. The results showed that the children failed to achieve recovery, although they improved in development. Moreover, data collected from parents' questionnaires reported a high degree of parental satisfaction with the treatment.
UCLA model has been broadly used, but apart from this, there are also some other model programs -behavioral and nonbehavioral- that are based on early intensive treatment for autism. Douglass, LEAP, May, Murdoch, PCDI, UCSF and Princeton are based on principles of applied behavior analysis and behavior intervention approaches; on the other hand, TEACCH, Colorado and Walden are nonbehavioral programs that use early intensive intervention (Dawson & Osterling, 1997).
These programs were studied by Dawson and Osterling (1997), and the outcomes provided a general view of the overall progress of the 150 children who received early intervention. Despite the differences of the programs, they shared some common elements: the curriculum content, the need for highly supportive teaching environments, the need for predictability and routine, a functional approach to problem behaviors, the transition from the preschool classroom, famly involvement, and finally, the intensity of intervention.
Smith (1999), reviewed 12 studies since 1980 (nine on behavior analytic programs, one on project TEACCH and two on Colorado). In sum, though all investigators reported substantial improvements, the nature of improvements varied substantially across studies. Some investigators found gains in all areas that they assessed; others obtained major gains in some areas, but smaller improvements in others. The most favorable outcomes occurred in the study that provided the most intensive intervention -the UCLA model.
As reported by Smith (1999), the UCLA model appeared to have in general, the fewest weaknesses in comparison to other programs, the strongest methology and the most favorable results. However, the study needs to be replicated using improved methologies. Two of three studies that have conducted partial replications of this study, have also reported favorable results. As a result, at this time, the long-term effects of the UCLA model developed by Lovaas and colleagues have been the most rigorously documented of any treatment model for children with autism. Other behavior analytic treatment programs almost certainly yield short-term benefits (Matson, Benavidez, Compton, Paclawskyj, Baglio, 1996).
In conclusion, one of the most important but also, exciting things in the field of autism, is the ability to recognize this disorder at a very early age (Dawson & Osterling, 1997). A lot of interventions have been used for autistic children or children with pervasive developmental disorders (behavioral and nonbehavioral). However, early intensive behavioral intervention has been proved to have the most significant results and specifically, UCLA model. Early intervention is proved to be very effective in most studies (e.g, Lovaas, 1987, Jones et al., 2007, Butter et al., 2006). In addition, high-intensive intervention has also been proved to have better results. The UCLA model implemented 30-40 hours per week and one-to-one direct instruction and had great effects on children's behavior; Smith's study (1999) provided evidence of the importance of the intensitivity of intervention, as in comparison to other programs, UCLA model was proved to be the most effective. Moreover, the effects of low-intensity behavioral treatment for children with autism and mental retardation, was shown in the study of Eldevik et al. (2006); gains were more modest than in studies, where children received a more intensive behavioral treatment.
As stated by Butter et al. (2006): "Early intensive behavioral intervention involves both prescriptions for how children with autism should be taught and what should be taught. The teaching methods of EIBI are based on principles derived from over 60 years of ABA research; including the use of reinforced practice, functional analysis, and single case experimental designs". It is a high structured program and the curriculum used in early intensive behavioral intervention programs is comprehensive and individualized to address the core symptoms of autism -severe language delays, impaired social interactions, repetitive and restricted behaviors (Butter et al.,2006).
Although there are studies that do not strongly support the positive effects of early intensive behavioral treatment (e.g., Boyd & Corley, 2001), there is strong evidence that EIBI is the most effective treatment in autism until now.
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- Smith, T. (1999). Outcome of early intervention for children with autism. Clinical Psychology: Science and Practice, 6, 33-49.