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Autism spectrum disorder is a clinical term used for a group of complex disorders of brain development. These disorders are characterised in varying degrees by difficulties in social interaction, verbal and non-verbal communication and repetitive behaviour. Children with Autism Spectrum Disorder (ASD) have difficulties in interpreting the things they experience hence anxiety and nervousness may arise as a responses to confusion in social situations. They may benefit from a means of communicating expectations and projected changes. Several types of strategies and policies are used in this learning process including work tasks, work environment, giving direct instructions and fewer choices, feedback /rewards, visual schedules and structures. Effective Educational Practices for Students with ASD includes foundations, teaching and learning, communication and behaviour, tools and techniques.
Human behaviour is basically refers to actions and skills as collective manner and that can be defined in several ways. Over the past twenty years, a variety of therapies have been proposed to improve the symptoms associated with ASD, many of which have not been validated scientifically. Behavioural therapy is a general term referring to the application of behavioural principles or philosophies, methods and treatments and interventions to address unusual patterns of behaviours. Applied behaviour analysis (ABA) is the use of multiple techniques and principles to bring about meaningful and positive change in behaviour. The aim is to improve the child's understanding of an experience by positive reinforcement and increased learning perspectives and consequently improves their engagement in learning. ABA principles and techniques can strengthens the basic skills such as looking, listening and understanding another person's perspective, conversing, imitating as well as functional academic skills such as reading and writing, basic math, time and money skills, self-care skills, domestics, recreation and social skills.
FOCUSSED CLINICAL QUESTION: What are the effects of applied behaviour analysis on the challenging behaviour of Children with Autism Spectrum Disorders?
SUMMARY of Search, 'Best' Evidence' appraised, and Key Findings:
30 citations were located that met the inclusion/exclusion criteria, including 4 evidence based guidelines, 4 research synthesis and 12 single system and case series designs. 4 research synthesis of case-series and single subject-designs was appraised
Four studies (single case series) by Svein Eikeseth et al., (2007), Jonathan M. Campell.,(2003), Virues-Ortega ( 2010 ) and Jonathan Green, (2012) were appraised. This study evaluated the frequency of specific behaviours, elicited by 12 children with autism, before and after behavioural therapy through applied behaviour analysis approach.
Patients stated that their children demonstrated improved attention, greater interaction with peers, decreased nightmares, improved transitions, better listening, greater self-awareness, better communication, improved sleep patterns, and more consistency in following directions
However due to the methodology of the study, results have little generalisability and external validity. Numerous single studies of varying levels of evidence, each also found within one or more of the reviews.
This synthesis reported that the current evidence base provides preliminary support for the use of social stories. However the empirical support is currently limited due to lack of high quality study designs and poor treatment integrity.
Key points for future research: employ more rigorous experimental control, examine critical components for developing social stories, examine factors related to implementation fidelity/treatment integrity, programming for maintenance and generalisation.
The study had some methodological limitations including concern about the reliability of outcome measures used.
CLINICAL BOTTOM LINE:
Applied behaviour analysis (ABA) has the aim of supporting individuals live as independently as possible. Preliminary evidence suggests that the application of Applied behaviour analysis (ABA) enhances the communication skills and improve social interaction skills and behaviours in children with ASD if developed and implemented according to specified guidelines in a manner suitable to the individual child's strengths and abilities. The study sizes of the studies encountered through the literature search are too small to generalize, and It would be very beneficial to have further research implement Level I studies with comparison groups. Evidence of increased attention and observed reports of social functioning make it a promising intervention to increase social participation in children with ASD.
Limitation of this CAT:
The limitations of this CAT include restriction to English language only studies, and the exclusion of non-randomised studies. Used convenience sampling and had a small sample size. This critically appraised paper (or topic) has been individually prepared as part of subject requirements and has not been peer-reviewed by one other independent professor.
Key words: Autism spectrum disorder (ASD), Applied behaviour analysis (ABA), Behavioural therapy, behavioural intervention, adaptive behaviour, Social skills
Impact of Applied Behaviour Analysis (ABA) and Early Intensive Behavioural Intervention (EIBI) in decreasing challenging behaviours and may improve skills in Children with Autism Spectrum Disorders.
Prepared by; Mehar Hobbi (email address:[email protected]
Date: 15 - 04 - 2013
Autism spectrum disorder (ASD) is a clinical term used for a group of complex disorders of brain development. These disorders are characterised in varying degrees by difficulties in social interaction, verbal and non-verbal communication and repetitive behaviour. Children with Autism Spectrum Disorder (ASD) have difficulties in interpreting the things they experience hence anxiety and nervousness may arise as a responses to confusion in social situations. Helping students to achieve to their highest potential requires both an understanding of ASD and its characteristics. They may benefit from a means of communicating expectations and projected changes.
Human behaviour is basically refers to actions and skills as collective manner and that can be defined in several ways. Behavioural therapy is a general term referring to the application of behavioural principles or philosophies, methods and treatments and interventions to address behavioural dissipations. Applied behaviour analysis (ABA) is the use of multiple techniques and principles to bring about meaningful and positive change in behaviour. The aim is to improve the child's understanding of an experience by positive reinforcement and increased learning perspectives and consequently improves their engagement in learning. The well-researched treatment programs are based on the principles of applied behavioural analysis (ABA), sometimes called behavioural therapy or behavioural modification. The approach has been outlined by Lovaas and colleagues in the 1980s and, as originally described, involves teaching appropriate behaviours by breaking tasks down into small discrete steps and training in a systematic and precise way called discrete trial training. ABA principles and techniques can strengthens the basic skills such as looking, listening and understanding another person's perspective, conversing, imitating as well as functional academic skills such as reading and writing, basic math, time and money skills, self-care skills, domestics, recreation and social skills. ABA is founded on behavioural principles of learning and motivation, consisting of reinforcement, extinction, stimulus control, and generalization.
Focussed Clinical Question: What are the effects of intervention of applied behaviour analysis on the challenging behaviour of Children with Autism Spectrum Disorders?
This question is formed using the PICO (population, intervention, comparison, and outcome) structure:
P = Children with Autism Spectrum Disorders
I = applied behaviour analysis
C = No comparison populations or interventions were used in this literature search.
O = Improvement of skills, behaviour, verbal and non-verbal communication and interest in activities or play skills.
Criteria for Including Studies in this CAT
Detailed below are the inclusion and exclusion criteria for each part of the PICO
The search was restricted to the English language only.
â€¢ The studies that involved applied behaviour analysis.
â€¢ Experimental studies that involved children diagnosed with Autistic disorder.
The study designs with systematic reviews and randomised controlled trials (RCTs) were considered.
â€¢ Reviews of experimental studies that involved the above mentioned criteria.
Studies published after 2000 & those published in journals.
â€¢ Studies that did not behavioural therapy.
â€¢ Studies published in other languages than English and published prior to 2000
Studies were to be excluded if no functional outcomes measured
â€¢ Studies that involved children with other conditions.
â€¢ Studies that did not target a specified behaviour outcome.
Studies that did not address applied behaviour analysis as a behavioural therapy or report on the impact of ABA on social behaviours and functional academic skills.
Terms used to guide Search Strategy:
Patient/Client Group: Children with Autism Spectrum Disorders, autism, autistic, autistic disorder.
Intervention (or Assessment): Applied behaviour analysis (ABA), Behavioural therapy.
Comparison: No comparison populations or interventions were used in this literature search.
Outcome(s): Improvement of skills, behaviour, verbal and non-verbal communication and interest in activities or social interaction.
Levels of evidence used (evidence-based clinical guidelines ) in evidence-based practices to describe the results in a clinical trial or research study.
The evidence from
Meta-analysis of Randomized Controlled Trials - 1a (level of evidence)
Randomized Controlled Trials - 1b
well-designed controlled trial ( not randomized) - 2a
well-designed experimental trial. ( Controlled trials, cohort study) - 2b
Case-control study, poor or non-independent reference standard - 3
Case series, case reports - 4
Expert's opinions without explicit critical appraisal, ideas, Editorials - 5
Databases and sites searched
Clinical guideline Sites
-National Health and Medical Research Council
-New Zealand Guidelines
Guidelines Network (SIGN)
Systematic review sites
OT seeker; PEDro
Illumina; Proquest; PubMed
Google Scholar ; Elsevier, Springerlink, JAMA, JABA
LOVAAS, Autism spectrum Australia (ASPECT), ResearchAutism, autismspeaks, Autism Research Institute (ARI)
(Autism OR Autism Spectrum Disorder) AND
(Applied Behaviour Analysis (ABA) OR
Early Intensive Behavioural Intervention (EIBI))
(autism OR ASD) AND
Behaviour Analysis and Early Intervention)
(autism OR autistic) AND
Behaviour therapy AND, OR
learning skills AND social
impacts OR Effects, Applied Behaviour Analysis (ABA) and Early Intensive Behavioural Intervention (EIBI) 'behaviuoral therapy', research,
School aged children with ASD
'applied behaviour analysis'
Published in previous 12 years (2000- 2013)
Included Eligibility Screening Identification IIIdentification
PRISMA FLOW DIAGRAM illustrating the search results for the CAT study.
RESULTS OF SEARCH
30 relevant studies were located and categorised as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 1998)
Table 1: Summary of Study Designs of Articles retrieved
Study Design/ Methodology of Articles Retrieved
Links appeared in: United healthcare website
Systematic reviews and meta-analysis of RCTs
Systematic reviews and meta-analysis of randomised and
RCTs, controlled trials, cohort
Case control studies
PubMed, PsycInfo, Proquest
Case series studies
PubMed, PsycInfo, Proquest, ERIC, CINAHL
Expert opinion including literature / narrative reviews, consensus statements, descriptive studies and individual case studies.
Illumina; Proquest; PubMed
Google Scholar ; Elsevier, Springerlink, JAMA, JABA
The following papers were identified as the 'best' evidence and selected for critical appraisal.
Intensive behavioural treatment at school for 4- to 7-year-old children with autism (Svein Eikeseth et al., 2007)
Efficacy of behavioural interventions in persons with autism (Jonathan M. Campell., 2003)
Applied behaviour analytic intervention for autism in early childhood: Meta-analysis, meta-regression of multiple outcomes. Virués-Ortega, J. (2010)
Early Intervention in Autism (Jonathan Green, 2012)
Reasons for selecting this study were:
â€¢ The primary purpose of the paper was to synthesise the limited existing research on applied behaviour analysis and their effectiveness for children with ASD.
Included school aged children with a diagnosis of Autism Spectrum Disorder.
Equal highest level of evidence methodology available to answer clinical question
â€¢ The individual studies in the review addressed my clinical question.
The paper highlighted and detailed limitations and strengths of individual studies.
â€¢ The paper represented the overall current level of evidence available for applied behaviour analysis and early intensive behavioural intervention.
â€¢ Other available research at same level was addressed in the synthesis.
SUMMARY OF BEST EVIDENCE
CAT: Description and appraisal of research synthesis by Svein Eikeseth, Tristram Smith, Erik Jahr and Sigmund Eldevik (2007).
Aim/Objective of the Study/Systematic Review:
To review and synthesise the existing research on Applied Behaviour Analysis (ABA) and Early Intensive Behavioural Intervention (EIBI) and their effectiveness for children with ASD.
Study Design: Case-control study (randomised controlled trial)
Setting: Both behavioural and eclectic treatment took place in public kindergartens and elementary schools for typically developing children.
Participants: The participants were standard referrals to the Habilitation teams that would have been made whether the study took place or not. All referrals agreed to participate in the study. Children with IQs fewer than 50 were excluded because previous studies had indicated that they may be less likely to benefit from intensive behavioural treatment. Children (n = 13; 8 boys) received a minimum of 20 hours per week of treatment for 1 year from trained therapists at their local schools. In addition to the 25 participants, there were 2 dropouts: One child who was assigned to the behavioural group (intake CA = 55 months, IQ = 52) received only 9.5 hours per week of treatment, although a minimum of 20 hours per week was planned.
Behavioural treatment was based on a manual (Lovaas et al., 1981) and associated videotapes (Lovaas & Leaf, 1981).
The treatment began with relatively simple tasks, and then progressed to more complex tasks, such as imitating verbal and nonverbal behaviours, labelling objects, identifying actions, and understanding abstract concepts such as colours, size, and prepositions. The treatment subsequently focused on advanced skills such as answering questions, conversing, and making friends with peers. The program also emphasized play and social skills, progressing from functional toy play and parallel play to symbolic and cooperative play.
Prior to the study, none of the therapists (teachers and aides) had had any supervised experience in the implementation of behavioural treatment for children with autism.
The therapists and parents took turns implementing the child's one-to-one, discrete-trial treatment programs, and they gave each other feedback on their work.
Children's Intellectual functioning, Visual-spatial skills, Language functioning and adaptive skills were assessed with the various instruments and Scales.
Table 1 summarizes the data on therapy. The average for all children in the study was 28.52 hours (SD = 6.83) per week. The children in behavioural treatment were significantly less likely to have goals for alternative/augmentative communication.
Table 2: Characteristics of Behavioural Treatment (n = 13)
Treatment hours (M [SD, range])
Daily living skills
Therapist education (n)
Less than 1 year
28.00 (5.76, 20-35)
Consistent with the results of the sign tests, the behavioural group showed more gains than the eclectic group on all measures. These differences were statistically significant for IQ, language and adaptive behaviour.
Analyses of clinical significance revealed that children in the behavioural group were more likely to have IQs in the average range. Seven of 13 in the behavioural group achieved WPPSI-R IQ scores above 85 (with 1 other scoring 84).
In the behavioural group, all correlations of intake age with outcome measures and changes in score were non-significant, with r(12) ranging from -.29 to .17. Thus, age was not reliably associated with outcome or amount of change in this group.
In the behavioural group, intake IQ was strongly associated with follow-up IQ and language. It was also positively but non-significantly correlated with follow-up Performance IQ and the adaptive behaviour.
Table: 3 - Unprotected Pearson Correlations of Intake Scores with follow-up scores and with changes in scores: behavioural treatment group (n = 13)
Adaptive Performance Behaviour Scales
NOTE: The first number in each cell is the correlation between intake and follow-up scores; the second number is the correlation between intake scores and change in scores.
*p < .05. **p < .01. ***p < .001.
Original Authors' Conclusions
At a 1-year evaluation, 13 children who had received applied behavioural treatment made significantly larger improvements. the results suggest that an effective intervention involves more than providing an intensive, comprehensive treatment program. Thus, our results suggest that the intervention can be successfully adapted to school settings for some children with autism. However, this adaptation may not be effective for younger children, such as those who have participated in previous investigations (e.g., Lovaas, 1987). Thus, further research is needed to determine whether younger children would benefit if the intervention were delivered at school rather than at home.
The researchers stated the purpose of the study. The population and intervention to be studied were described in detail.
â€¢ The research could have been much more comprehensive as it included only two databases. The research on 'Applied Behaviour Analysis' for this CAT was wide ranging including more than ten databases, various websites and specific journals; however it only derived a few more studies of similar quality published 2010-2013. This CAT excluded a large volume of non-experimental level 5 evidence.
â€¢ Other studies were excluded due to lack of targeted outcome behaviours and minimum expected experimental control. No predetermined criteria for inclusion were stated.
â€¢ The review reported on the following qualities and details for each study: Inter-observer agreement, threats to internal and external validity, experimental control, alternative explanations for change in observed behaviours, treatment integrity, social validity, combination of treatments or multiple treatments occurring simultaneously and appropriateness of selected study design. These findings are reflected in other available case-series designs. No predetermined strategy for establishing the quality of each study was stated.
â€¢ Most individual studies were reported to show a decrease in unwanted behaviours, and some studies reported positive improvements in social skills.
â€¢ The studies employing a multiple baseline design and ABAB design observed higher treatment integrity, social validity and inter-observer agreement than other studies. Although it is difficult to control for external variables that may influence the child's behaviour due to the nature of the disorder these studies were able to replicate results which indicate some effect from the intervention.
Results were presented in the text, but not clearly presented in a consistent and precise manner. For some studies, results were expressed as 'significant' without empirical support. (Poor or lack of presentation of results, lack of predetermined evaluation strategies, inconsistent reporting, no analysis or results).
Interpretation of Results
â€¢ This research synthesis provided much needed information about the effectiveness of Applied Behaviour Analysis as an evidence-based practice for children with ASD.
â€¢ Although the quality of each study was not evaluated in great detail, Individual studies were objectively critiqued and compared. A collective conclusion was drawn about the existing level of evidence in currently available research.
â€¢ Results were presented in the text and descriptive statistics were drawn from available data. Decrease in challenging behaviours reported to be between 10 and 100%. Increase in social interaction, choice making, and communication reported to be 22 to 50% in one study. Otherwise, no empirical results displayed.
â€¢ Various limitations of each individual study were presented and discussed in this review. Particularly the two AB designs lacked experimental control with no replications of results.
â€¢ Participants in the studies were children aged 4 to 17 years, with a diagnosis of ASD, although the disability severity varied. Treatment settings included the child's home, special education facility or mainstream school classrooms.
â€¢ The available research reports positive outcomes of the use of Behavioural treatment with children with ASD, however the evidence for the effectiveness of ABA is limited due to the lack of high quality studies and lack of empirical analysis of available data.
â€¢ It would have been useful to have all data presented in a uniform fashion, in order to contrast individual studies. Information about clinical significance of behaviour change would also have been valuable.
The article supports the use of visual supports with children to signal transitions but lacks a high level of evidence or generalizability. Further research is needed to confidently apply these to techniques within this population of children.
Results suggest that long-term comprehensive ABA interventions have positive effect on intellectual functioning, language, daily skills, and social functioning. Effect sizes varied between outcomes, lowest in nonverbal IQ, and daily living skills, and social functioning. Clinic-based interventions were slightly superior to parent managed interventions. Sensitivity analysis showed similar outcomes when meta-analysis was restricted to controlled trials. Results must be interpreted cautiously due to the multiple limitations described above.
In this study, due to more than one paper is included; a further table that provides a comparative summary of each paper may be added.
COMPARATIVE SUMMARY OF BEST EVIDENCE
Table 4: Characteristics of included studies
Svein Eikeseth et al., (2007)
Jonathan M. Campell.,(2003)
Virues-Ortega (2010 )
Jonathan Green, (2012)
Behavioural treatment through ABA and Early Intensive Behavioural Intervention
ABA intervention programs for preschool children with autism and other ASD
intervention for children with autism
ABA /EIBI interventions
emphasized play and social skills, adaptive behaviour
The Lovaas treatment approach
The Lovaas treatment approach
Functioning on motor skills domain. Living skills and overall composite adaptive scores.
Intensive Behavioural Intervention
behavioural therapy or behavioural modification
Discussed in detail in Appraisal. Generally, the social, learning and communication skills enhanced after behavioural treatment. High intervention intensity was the only variable that independently predicted both IQ
and ABC gain.
No interaction terms were statistically significant independent predictors of
IQ or ABC change.
Pooled results show no additional benefit of applied behavioural intervention vs. the other interventions in the studies in young children with ASD.
Higher inter-rater reliability of behavioural observation may reflect greater treatment integrity, perhaps because problem behaviour is well defined and reliably observed by multiple persons responsible for implementing treatment. This implantation of behavioural intervention can influence the degree of behavioural suppression.
Results suggest that long-term comprehensive ABA interventions have positive effect on intellectual functioning, language, daily skills, and social functioning. Effect sizes varied between outcomes, lowest in nonverbal IQ, and daily living skills, and social functioning. Clinic-based interventions were slightly superior to parent managed interventions. Sensitivity analysis showed similar outcomes when MA was restricted to controlled trials.
Results must be interpreted cautiously due to the multiple limitations described above.
ABA /EIBI interventions were associated with improved outcome.
There is insufficient evidence from well-conducted large randomized comparative trials with long term follow-up to determine which comprehensive treatment approach is best for young children with autism, and in particular the most effective treatment for teaching specific skills given certain profiles and characteristics of the child.
IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH
Over the past twenty years, a variety of therapies have been proposed to improve the symptoms associated with ASD, many of which have not been validated scientifically. Despite the limitations of this research synthesis, it presents the best available evidence for the use of applied behaviour analysis, with children diagnosed with ASD. Evidence for continued use of early intensive behavioural intervention is promising but preliminary, and highlights the need for more rigorous higher level research such as randomised controlled trials, into the use of behavioural treatment.
â€¢ Paediatric occupational therapists are unlikely to have received direct training in the development and use of social stories. For best outcomes, it is important to follow the comprehensive information and instructions on how to design and implement this strategy. Such instructions are readily available from the developer's website at no cost (Gray, 2002 - see reference list). The website also provides sample social stories for common difficult situations.
â€¢ It is important that the applied behaviour therapy is adapted to the child's age, interests and comprehension level and written in a positive, reassuring language (Gray, 1995). It may take some practice to exchange strengths and abilities to the children for promotion of social integration and functional performance.
â€¢ Children with ASD typically receive various types of long-term interventions simultaneously, a fact reflected in the articles included in the synthesis. This fact makes it difficult to attribute behaviour change and social skills acquisition to ABA exclusively. Evidence-based guidelines note that multiple treatment strategies lead to the most successful outcome for children with ASD (Perry & Condillac, 2003; Roberts, 2003). Therefore, ABA should be considered for specific difficult situations concurrently with other interventions.
â€¢ Main implications for future research include observation of treatment integrity and implementation fidelity, generalisation of skills across various situations, rigorous experimental control such as ensuring prescribed intervention implementation and controlling for other interventions being received, concurrent to the this approach.
â€¢ The approach of ABA is based on the concept that children with ASD have significant difficulties with learning, being unable to learn through imitation, and listening as normal children do. With practice, ABA require comparatively long time to prepare and are a cost-effective alternative or complimentary social skills tool.
â€¢ The use of various strategies for ABA is recommended to inform and guide the child with ASD through novel, stressful, and challenging situations.
There is need for further research to address ABA, specifically teaching tools or approaches that are used with children diagnosed with ASD or other developmental disabilities. Current research on the topic has a low level of evidence and is not generalizable to other children. A validated tool to assess the usefulness of a visual support system with a child is needed so that validity of results is stronger. Larger studies, investigating more than one subject are needed to increase the ability to generalize the information to the general population of children with ASD. Each article used in this critically appraised topic varies the way the intervention was used and presented to the child. Further research could explore standardizing the procedure and tools.