| Recent Article Summaries |
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| Written by Administrator |
| Monday, 26 April 2010 18:50 |
Welterlin, A., & LaRue, B. (2007). Serving the needs of immigrant families of children with autism. Disability and Society, 2 (7), 747-760.Reviewer and primary author: Aurelie Welterlin, Psy.M. The article addresses the topic of increasing awareness of how immigrant families in the United States manage health care. Although applicable to a broad range of mental and physical disorders, the article narrows its focus on families of children with autism spectrum disorders (ASD). Written for both families and practitioners, it provides a conceptual framework of how cultural values and beliefs shape the way diagnosis, etiology, and treatment of ASD is perceived by both immigrant families and western practitioners, and how differences in perspectives may create obstacles in treatment planning. A review of literature describing practical and cultural barriers to mental health access among immigrant populations is also presented. Finally, recommendations are offered to practitioners and families to aid in increasing collaboration. The authors begin by noting the rapid increase of immigrants in the US and how this movement has had major implications for the delivery of culturally competent health care services. ASD, they state, is a condition requiring intensive and well managed care, which, for the immigrant population, may be difficult to obtain without awareness and direction on both the family and practitioner's end. The driving theory presented by the authors to address the health care of immigrant families is the ecocultural theory, a perspective that considers the sociocultural environment of the family (Gallimore et al., 1996). This theory has been previously applied in the ASD literature by Brookman-Frazee (2004) and Moes & Frea (2002), who propose that intervention procedures should be based on a "contextual fit," tailored to accommodate the needs, values, goals, and systems that make up the ecocultural niche of a family. The first consideration presented by the authors is how disability is defined and interpreted across cultures. The authors suggest that families who immigrate to the United States may have specific views of what constitutes a disability, different from western views, which may be largely based on their unique social and cultural background. The authors raise the issues that the western 'medical model' approach that has adopted mental health classification systems which reflect beliefs that some individuals do not behave or function "normally" in society, may not be the framework used by other cultures. In fact, the authors note, some cultures may not even mark the same conditions as disabilities. The authors also discuss differences in how some cultures understand the etiology of medical conditions. They state that, for example, some religious Latino and African American families believe that bearing children with a mental illness is a gift from God (e.g., Heller, et al., 1994). The second consideration presented by the authors is how impressions of normalization and intervention may differ across cultures. Whereas the dominant culture in the United States is based on a certain set of beliefs and values that define the mainstream idea of a normal, good quality of life (e.g. independence, self reliance, personal choice, etc.), immigrant families may not share the same normalization principles as American parents and professionals, and may not, as a result want the same intervention goals. One example provided is the goal of teaching sustained eye contact, which may be rejected by Asian-immigrant parents who regard their children as disrespecting them if eye contact is established (Shu-Minutoil, 1995). The authors note that little research exists that examines the assumptions and expectations of immigrant families on competency and skill development of their disabled children, however, they do provide some of the beginning evidence. Approaches to treatment may also vary across cultures; state the authors, due to beliefs about etiology. Some immigrant families with established beliefs from their home country may rely on family members, elders, and spiritual and folk healers for information and treatment. The authors end their discussion providing a description of some of the practical barriers to receiving health care services faced by immigrants, which are primarily based on lack of knowledge, financial recourses, and ability to communicate. The authors end their paper with a discussion of recommendations for both service providers and immigrant families concerning how to negotiate differences. For service providers, they suggest incorporating the components of a family's social and cultural environment to create a "best fit" intervention, which will lead to increased efficacy and compliance to an intervention. They suggest having frank discussions about views of diagnosis, etiology, and treatment with immigrant families and also provide suggestions of how practitioners can become culturally sensitive and competent. For immigrant families, the authors recommend taking an active role in developing and implementing interventions, educating themselves about assessment and intervention processes, and in teaching service providers about family and cultural norms, values, preferences, expectation, concerns, and priorities. They also provide Brookman-Frazee's (2004) criteria to help families become evaluative of practitioners, while normalizing the fact that providers may be sincere but merely uninformed. References
Todd, T., & Reid, G., (2006). Increasing physical activity in individuals with autism.Focus on Autism and Other Developmental Disabilities, 21(3), 167-176.Reviewed by: Megan Atthowe, RN, BCABA The benefits of sustained physical activity to human health and fitness are well-established, and initial research with individuals with autism suggests that it may have the additional capacity to enhance desirable behaviors and to reduce problematic ones. Unfortunately, however, individuals with autism face a number of barriers to engaging in physical activities, both by virtue of the characteristics of the disorder and the dearth of research-based guidelines on how to intervene effectively. Self-monitoring (inclusive of self-observation and self-recording) is one technique used to increase behavior while limiting the extent of external feedback delivered. This technology is easy to replicate and is conducive to use in a variety of settings. Evidence from research on self-monitoring in both typically-developing and mildly-disabled populations suggests that it can be an effective intervention for increasing physical activity. The purpose of the present study, then, is to extend this research to individuals with autism by examining the effects of an intervention package (self-monitoring, edible reinforcement, and verbal cuing) on participants' physical activity during 30-minute exercise sessions. Three nonverbal, ambulatory young men with autism, ages 15-20 years, participated in this study. All three participants attended a Canadian school for people with developmental disabilities, had been exposed to structured teaching, and had not used self-monitoring systems previously. The investigators selected two outdoor physical activities for intervention: snowshoeing (a total of nine sessions during snowy months) and walking/jogging (23 sessions during spring and early summer). Because these activities are normative in Canada and require little equipment and few complex skills, the investigators' selections could have facilitated community inclusion, generalization, and the potential for maintenance in the natural environment - thereby sustaining the benefits of physical activity beyond the timeframe of the study. Sessions occurred twice per week and lasted one hour (15 minutes each of preparation and clean-up and 30 minutes of physical activity). The activities were conducted on a soccer field; during inclement weather, sessions were either cancelled or moved indoors (walking/jogging only). Participants followed a 57m x 50 m, diamond-shaped course, demarcated by a bench in one corner of the diamond and a flag in each of the other three corners. The bench served as the starting and ending points of each lap and held the participants' self-monitoring boards. The investigators used a changing conditions design to examine the effects of a three-component intervention on participants' snowshoeing and walking/jogging behaviors. Three conditions were included: baseline (A); self-monitoring, edible reinforcement, and verbal cuing (B); and self-monitoring and verbal cuing only (C). Data were collected on the number of laps each participant completed, measured by the number of markers on the self-monitoring board at the end of each session. Participants snow shoed during all four sessions in condition A and during the first five sessions in condition B. Walking/jogging began during condition B (session 10) and continued through the end of the study. The self-monitoring component of the intervention consisted of a board with three columns, each of which was labeled with a participant's name in an assigned color. During conditions B and C, each time a participant completed a lap, he placed a color-coded happy face marker in the column under his name. The investigators taught participants how to place the markers on the self-monitoring board using hand-over-hand guidance during the first three sessions of condition B. After the third session, prompting was withdrawn unless the participants were unable to complete the act independently. The investigator or a staff person remained with the self-monitoring board throughout the study and gave each participant a happy face marker to put on the board each time he completed a lap. The edible reinforcement component of the intervention was incorporated to be consistent with the participants' school program. During condition A (baseline), no edibles were delivered. During condition B, edibles were given initially at each corner of the diamond course (for a total of four edibles per lap). Delivery of edibles was then systematically faded by delivering one less edible per lap every four sessions until participants received only one edible per lap (paired with delivery of the happy face marker). During condition C (the last four sessions of the study), no edible reinforcers were used. The verbal cuing component of the intervention consisted of verbal encouragement and verbal directives, neither of which was manipulated systematically. Verbal encouragement included praise for exercising or completing laps and statements intended to cue participants to increase their pace if they slowed or stopped. Verbal directives included instructions about following and staying on the course. The number of verbal cues delivered in a session was recorded every three sessions via a microphone. The average number of laps completed per session increased for all three participants over the course of the study. By the end of the nine snowshoeing sessions, all participants had increased their average distance by 0.2 km. By the end of the walking/jogging sessions, the three participants increased their average distance by 1.26 km, 1.14 km, and 0.83 km, respectively. Distances increased despite the systematic decrease in edible reinforcement. An increase in the participants' independence was inferred from the decrease in verbal cues provided over time. Temporary increases in verbal cues were noted on the three days that the course was moved to another outdoor area and on the day that jogging was introduced. While the results of this study are promising and suggest that physical activity can be increased and maintained with self-monitoring, the characteristics of the changing conditions design limit the conclusions that can be drawn. First, we cannot know what component(s) of the intervention served to reinforce and maintain the target behaviors. While participants' behaviors increased and persisted despite a decrease in external reinforcement, we cannot conclude that the self-monitoring (the only part of the intervention that remained constant in conditions B and C) led to the behavior changes. That is, we do not know whether the self-monitoring or something else led to changes in the dependent measures. Second, it is difficult to compare conditions A and C with confidence, as the participants snow shoed during condition A and walked/jogged during condition C. Thus, part of the participants' increased distance could be due to a change in the activity itself. Additional research incorporating alternate designs, additional measures, and careful data analysis is needed to clarify the effects of self-monitoring on physical activities. Despite its limitations, this study makes a valuable contribution to the small and much-needed body of literature on physical activity in this population. First, the study demonstrates that it is possible to increase the physical activity of students with autism and to sustain the activity with decreasing levels of external feedback. Its findings are encouraging, particularly to those working in settings where independence is expected and feedback is rare. Second, the target skills were well chosen and may help the participants engage in behaviors that are more reinforcing to others. Third, inasmuch as self-monitoring may increase independence across a variety of settings and behaviors, the field should continue to explore its use for individuals on the autism spectrum, including adults. With only emerging evidence to support its use in this population and in this area, however, practitioners in applied settings who wish to try this or similar interventions should take care to do so only when data-based decision making can be assured. Megan Atthowe is a graduate student in the School of Nursing at the University of Virginia and currently works as a program director at the Virginia Institute of Autism. Her interests include the development of behavioral programs and community supports for older learners with autism and underserved populations. Megan currently holds a BCABA and is in the process of completing the requirements to sit for the BCBA exam.
Taylor, B., Hughes, C., Richard, E., Hoch, H., & Coello, A., (2004). Teaching teenagers with autism to seek assistance when lost. Journal of Applied Behavior Analysis, 37, 79-82.Reviewed by: Jennifer L. Buck, M.Ed., Special Educator, Charles C. Knowlton School, Ellsworth, Maine Over the past decade, it has become apparent that the safety of our children is of the utmost importance. While walking through a local store, we may hear small voices calling out "mommy" or "daddy" in search of a parent that may have become momentarily separated from their child. What happens, however, when a child lacking social and/or communication skills becomes separated from their parent(s)? What happens if this young child has autism, and is unable to speak? This current study investigated different strategies to teach individuals with autism how to seek help when lost in the community setting. This study evaluates the efficacy of teaching individuals with autism to respond to a tactile prompt and seek assistance when separated from a parent or teacher. The participants included three students that met the diagnostic criteria for autism, and also had deficits in communication and socialization skills. Each of the participants were given a J Tech vibrating pager and an identification card, which included the student's name, a statement that he or she was lost, and an emergency contact information. The participants wore the J Tech pager on the rim of their pocket or waist band during all training sessions. The dependent measure in this study was the percentage of correct responses to a page during each teaching trial. During each trial, a student was required to approach an adult, gain the attention of an adult by saying "excuse me," hand their identification card to the adult, and wait to be reunited with their parent or teacher. Baseline data were collected in five different community sites. Teaching sessions took place at two of the five sites and at school, while the remaining three locations were used as generalization settings. During baseline probes, the student was accompanied by a teacher to each setting. The J Tech pager and identification card were located on the student. An unseen observer watched over the student as the teacher slipped out of view, and collected data on whether the student approached an adult when the teacher disappeared (the pager was not used). Approximately two minutes after the trial began, it was ended when the teacher returning to the student. A multiple baseline probe design across participants was used to assess the effects of a tactile prompt in relation to seeking assistance when separated from an adult. The participants were first taught how to respond to a page by giving a familiar adult their identification card. Physical guidance was used to guide the student to the nearest adult, followed by a verbal prompt of "excuse me". The student was then manually guided the student to retrieve the identification card to give to the adult. Students were reinforced with praise and edibles for correct responses and were eventually faded. Community teaching at two locations occurred only after the participants were able to retrieve and give their identification card to a familiar adult. One or two teaching trials were conducted during each outing. Community teaching sessions involved all of the same procedural safeguards that were in place during baseline data collection, with the exception that the teacher activated the pager when the student became separated from him or her. The participant had 30 seconds to produce their identification card, if the student was unable to do so, a least to most prompting hierarchy was implemented. Generalization probes at new sites included no tangible reinforcement or error correction. The student was given 30 seconds to produce their identification card. If the student was unable to produce the card, the pager signaled again, followed by praise, once the student was reunited with the teacher. If the student did not respond by retrieving their identification card, the trial was abandoned and the student was reunited back with his or her teacher. Parent probes were conducted in the same manner as the community teaching sessions, except the parent accompanied the student and activated the pager. The criterion for training at all locations was 100% correct responses over three consecutive teaching trials. Each student that participated in this study was able to produce his or her identification card in response to a tactile prompt, at school and in each of the community training locations. More importantly, these three participants were able to generalize this particular skill across teachers, familiar adults and their parents and approach both familiar and unfamiliar people for help. Future studies should include seeking help from known community helpers, such as, store personnel, security guards, or a cashier to protect students from unsafe strangers. With the way that technology is ever changing, I see our young children evolving with this change. Global positioning systems are becoming more and more sophisticated each year, and may be potentially useful in helping us locate lost children. Until then, this teaching strategy may help give children the skills they need to find parents and other adults when lost, rather than leaving the "finding" up to the adults.
Stromer, R., Kimball, J.W., Kinney, E.M., & Taylor, B.A., (2006) Activity Schedules, Computer Technology, and Teaching Children with Autism Spectrum Disorders. Focus on Autism & Other Developmental Disabilities 2(1), 14-24.Reviewed by: Sarah Land Activity schedules are commonplace additions to classroom and home settings for individuals with autism. The more traditional form of activity schedule is a notebook activity schedule. With technological advances, as well as further research into video modeling, activity schedules can now utilize computers. The authors discuss the research on both types of activity schedules, as well as the benefits and drawbacks of computer activity schedules. Additionally, topics for future research are presented. The authors compare notebook activity schedules to "to do lists" because they often serve as functional cues for skills that normally require prompting from staff. Notebook activity schedules can also promote independent task initiation and completion, while reducing undesired behavior during transitions (Schmit, Alper, Raschke, & Ryndak, 2000). Furthermore, notebook schedules can be used to teach new skills via schedule- following. MacDuff, Krantz, and McClannahan (1999) found students could follow both trained and novel orders of schedules. The students also generalized to other activities that they were familiar with, but that had not been included in the original trained schedule. There is a large body of support for the benefits of notebook activity schedules. Parents who used the notebook schedules at home increased engagement and social initiation, and decreased disruptive behaviors (Krantz, MacDuff, and McClannahan, 1993). Additionally, notebook schedules may have more functions than simply that of an environmental modification. Notebook activity schedules can be utilized to teach interventions for self-management and choice making. Students can be taught to choose the activities, the order, and even the reinforcer. Researchers have also combined notebook activity schedules with common methods of increasing play and social skills. Krantz and McClannahan (1998) taught students to utilize photos and text within notebook schedules to seek adult attention and praise for an activity. When the scripts were faded, the children initiated scripted and unscripted comments. They also initiated comments for different activities and solicited attention from differing conversational partners. Computers have also been used to create activity schedules. This can be particularly helpful for children with autism for a multitude of reasons. First, using computers for schedules can be worthwhile because students often are reinforced by computers. In fact, students frequently prefer computer-based instruction over teacher instruction (Romancyk, Weiner, Locksin, & Lekdahl, 1999) and access to computer activities can even be used as a reinforce (Thorp, 2001). Second, one of the additional benefits of computer activity schedules is the ability to incorporate new technology, such as video modeling, into the schedules. Video modeling consists of the student viewing a recording of an individual performing the desired skill at a criterion-level of performance. Video modeling is especially helpful because it is able to bring a multitude of settings to the student, is consistent in demonstrations of the appropriate model, and may be reinforcing for the student to watch. Using video modeling may also be more effective than using live modeling (Charlop-Christy et al. 2000). Video modeling has been used to teach skills in purchasing, communication, play, and self-help. Third, both academic and play skills can be learned via computer schedules. Academic skills, such as spelling, math, money, and number skills can be taught as embedded tasks using video modeling within computer activity schedules (Vedora, Bergstrom, Kinney, & Stromer, 2001; Kimmey et al., 2003). Kinney et al. (2003) utilized matrix training to teach a young girl spelling skills. After quickly learning the desired target word sets both picture and dictation cues and learning to write schedules, she generalized both to spelling untrained words and imitation of novel video displays. In addition to teaching academic skills, computer activity schedules have been used to effectively teach play and commenting skills. Kalagian, Kinney, Taylor, Stiner, and Spinnato (2002) taught a 6-year-old girl to follow a computer schedule including independent play, sociodramatic play, and play bids. The girl learned to manipulate and attend to the computer schedule properly, retrieve the materials and script the dialogue. In addition, play generalized to both notebook schedules with pictures and with only textual messages. A similar example of using a computer activity schedule to teach play and commenting skills can be found in Dauphin et al. (2004). The researchers taught appropriate toy play skills to a 3-year-old boy in the home setting via a schedule with photos and video models of an 8-year-old boy demonstrating appropriate play and comments. The study used matrix training to teach generalization. After learning the three target routines, the child was able to perform 6 untrained activities when presented with only photos on both his computer and notebook schedule. Finally, computer schedules may assist in teaching students to attend to multiple cues by using various auditory and visual stimuli. Schedule following is not disturbed by rearranging sequences or presenting various cues individually. The authors suggest that students comprehend relations among stimuli and can attend to stimuli even when they are not required to, evidenced by students who can perform naming and matching tasks with cues when embedded in the schedule. The authors recommend researching whether only some of the cues or some component of the schedule have stimulus control. Also, research on whether having multiple stimuli facilitates learning categories and classes of stimuli, as well as whether requiring a student to actively name a stimuli facilates learning functional verbal skills, is desired (Dauphin et al., 2004; Kalagian et al., 2002; Kinney et al., 2003; Vedora et al. 2001). Some issues do arise with utilizing computers. Notably, computers are not portable. Because of this, the authors suggest transferring stimulus control to notebook schedules quickly and to create a package intervention combining both notebook and computer activity schedules to gain the unique advantages found in each while facilitating independence. Also, computers can be expensive and fragile, so the authors suggest using it for multiple purposes to make it more cost-effective. In addition, there is a lack of commercially available products and it can take a great deal of time for staff members to become acquainted with the software and to produce effective schedules. For that reason, the authors promote teachers developing skills using PowerPoint or HyperStudio. Finally, because computers are reinforcing to students, students may not want to leave the computer. Finally, difficulties can arise in generalizing from on-schedule behavior to off-schedule behavior (Bryan & Gast, 2000). The authors present various recommendations for future research. One such area is determining what type of students would benefit most from the differing types of activity schedules as well as identifying the critical skills needed and the teaching steps necessary for students to learn from video modeling. Research is also needed on how researchers can promote choice making and engage a child when the schedule is not in use. Another area of potential research entails understanding how to shift control to photos or text, as well as from more cues to fewer cues. Finally, more research is needed to determine whether computer activity schedules can promote skill acquisition faster than conventional instruction. In conclusion, the authors deem activity schedules practical and beneficial tools for students with autism. The current evidence is persuasive enough to warrant the additional study of this topic. Sarah Land is an undergraduate student at Rutgers University majoring in Psychology. She currently works as a research assistant at the Douglass Developmental Disabilities Center.
Hertzroni, O.E., & Tannous, J., (2004). Effects of a computer-based intervention program on the communicative functions of children with autism. Journal of Autism and Developmental Disorders, 34(2), 95-113.Reviewed by: Melissa Ortega, M.A. One of the hallmark traits of autistic disorder includes impairments in communication. This may vary for individuals as delays in or lack of communication, impairment in initiating or sustaining conversations, or repetitive and stereotypic use of language (Wetherby & Prizant, 2000). Interventions to enhance communication for people diagnosed with autism are continuously being developed and the utilization of technology (e.g., video, television, and computers) has been an area of interest to further investigate to help create new approaches for teaching skills such as functional communication. Historically, computers have been found to be successful teaching instruments for children with autism through various facets (Chen & Bernard-Optiz, 1993; Colby, 1973; Higgins & Boone, 1996; Panyan, 1984). Hertzroni and Tannous developed a software program that is based on daily life activities and was taught to study participants in a controlled and structured setting to investigate whether children with autism could learn specific language skills within this type of environment. Hertzroni and Tannous highlighted the difficulties children with autism have with the understanding of concepts, communicative interactions, and representational thought. These deficits are said to be linked to the theory of mind (ToM) (Baron-Cohen, 1988; Tager-Flusberg, 1997) which is the ability to use predictive skills to understand relationships between external states of affairs and internal states of mind. Furthermore, ToM is associated with understanding, organizing, using language appropriately in a functionally communicative manner. Children with autism can have impairments in these areas in various degrees of severity, and can be expressed through immediate echolalic speech (repetition of words heard immediately or later after being heard) and irrelevant speech. Hertzroni and Tannous sought to increase the opportunities to interact in an environment that modeled language in appropriate settings to enhance communication and ideally advance the development of language (Mesibov, Schopler, & Hearsey, 1994). The study included 5 participants (3 females, 2 males) between the ages of 7.8 and 12.5 years old. The criteria to participate in the study required the formal diagnosis of autism, functional communication mainly by immediate or delayed echolalic speech, irrelevant speech, or intentional communication attempts, normal hearing, vision, and mobility. The participants also had access to a classroom computer. A multiple-baseline design was implemented with computer-based training with three distinct settings highlighted: playtime, hygienic activities, and mealtime scenarios. During baseline, students were observed during the three natural training settings (meals, hygiene, and play). Data was collected on the dependent variables, which included frequency of delayed and immediate echolalia as well as relevant speech. Following baseline, the intervention was applied to the first setting (play). Each student was trained in a computer room outside of their classroom. During the intervention, the student viewed scenes of the training setting on the computer. The program asked questions in the selected scenarios that would elicit the participant to choose between items (e.g., toys, food items, or hygienic activities). Once the participant chose an item an animation of the activity that was chosen would appear. This pattern was repeated throughout the duration of the session with new activities for the participant to choose from, each followed by animations. The sessions were terminated by the participant (either from completing the activity or because wanted to quit). There were no verbal interactions that were required, simple neutral praise was provided intermittently during the training phase on the computer. During intervention, observations of the students in the natural environment were still conducted, coding for echolalia and relevant speech. After six sessions (approx. 10-min each) of intervention in one setting, intervention was applied to the next simulated setting. This pattern repeated until the participant had been exposed to all of the trained settings. The intervention results indicate a significant reduction across all participants was in sentences involving delayed echolalia. Regardless of setting, all participants had reductions in sentences spoken with delayed echolalia. The next significant gain for participants was with relevant speech, especially during play and mealtime activities. Initiation of interactions and communication increased for all of the participants. Not all of the trained settings had significant positive results, however. In the hygiene setting, the improvements in the use of functional communication were slight compared to the other two conditions. The authors hypothesized that this was due the participants' activity preferences. The most highly preferred activities involved food and toy items, while hygienic activities were the least preferred for the participants. The results from this study support the effectiveness of computer-based functional communication training in structured settings on daily activities. These results are promising for the future development of programs to assist in the training of functional communication in the natural environment. Furthermore, the findings were significant in the reduction of inappropriate, noncommunicative speech across all settings. It is the authors' hope that computer programs that enhance communication for children with autism and with different communication deficits, could foster a greater understanding of the theory of mind (ToM) and impairments of communicative functioning. This article provides promising results for the future development of technologically advanced methods for teaching functional communication to children with autism and language deficits. The greatest benefit with computer-based training programs is the consistency in training and exposure the learner has to acquire new skills. Future studies should include computer-based training programs in community settings and in the home environment. Melissa Ortega, M.A., is a graduate student in the Graduate School of Applied and Professional Psychology at Rutgers University and currently works as a classroom behavioral consultant at the Douglass Developmental Disabilities Center.
Stahmer, A., Collins, N., & Palinkas, L. (2005). Early intervention practices for children with autism: Descriptions from community providers. Focus on Autism and Other Developmental Disabilities, 20(2), 66-79.Reviewed by: Robert Babcock, Ph.D., BCBA As the title suggests, the aim of this study was to gain a better understanding of the early intervention services provided to children with autism in community settings using provider reports. This serves as an initial step in research necessary to determine whether and how empirically supported treatments are being adopted in community programs. The authors point out that several behaviorally based - and a few non-behaviorally based - methods are supported by research. Among the most efficacious, research-based methods are Discrete Trial Training (DTT), Pivotal Response Training (PRT), and Incidental Teaching. In addition, effective programs have been demonstrated to contain common elements, including individualized supports and services, systematic instruction, an understandable and structured environment, a curriculum tailored to the needs of children with autism, a functional approach to problem behaviors, and family involvement. The study conducted four focus groups composed of primary service providers drawn from 22 early intervention (EI) programs in two counties within which a total of approximately 550 children with autism ages 0-5 years received services. Almost all participating providers had a bachelor's (11) or master's (8) degree, with an average of about 10 years of experience working with children with autism spectrum disorders (ASD). Each participant gave a brief overview of their program for children with ASD. They then read two age-matched vignettes depicting case histories of children with ASD and answered questions aimed at assessing what types of programs they would set up for each child, the extent to which they would individualize the programs for each child, which techniques they considered to have adequate research supporting their effectiveness, additional techniques they might use or that they did not like to use, and any techniques that they had discontinued along with the reasons for discontinuation. To conduct a qualitative analysis, transcribed audiotapes were independently coded and final codes were constructed by consensus, developing a list of themes, issues, accounts of behavior, and responses to the presentations of the vignettes. Results yielded interobserver agreement levels of 93% to 95% when the coding system was applied to the transcripts. Primary themes included (1) using research-based practices, (2) understanding which practices are supported by evidence, (3) selecting interventions, (4) adapting interventions, and (5) specific training. Transcripts were also coded to identify best practice elements common to excellent autism programs. For a quantitative analysis, the numbers of participants reporting use of specific techniques were tallied. Of 30 interventions that were listed by participants, the most common methods they reported using, in descending overall order, were picture exchange communication systems (PECS, 95%), occupational therapy (OT, 77%); applied behavior analysis (ABA), broadly defined to exclude DTT and PRT (73%); Floor Time (68%); DTT (64%); Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH, 55%); Sign Language (50%); PRT (32%); Music Therapy (23%) and minimal use of any specific intervention programs (18%). Techniques that participants considered to have a solid evidence base were ABA, DTT, music therapy, OT and sensory integration, PECS, PRT, and TEACCH. While only one-third of the 30 interventions identified by participants were actually either evidence based or had some evidence of efficacy, the groups endorsed, by consensus, 50% of these methods as being evidence based and were able to agree by consensus that only 30% of these interventions had either poor or no research support. Participants also reported making adaptations of research-based procedures in their programs, the most common adaptation being the inclusion of multiple techniques in one program. Most participants (76%) reported selecting interventions based on the child's characteristics, with DTT being used more for children with limited skills; naturalistic techniques being used to promote generalization, increase motivation, teach social interaction skills; and sign language and PECS being used for nonverbal children. A more detailed discussion of the results, including how participants reacted to specific procedures, is both interesting and informative but well beyond the scope of an article summary. The authors concluded that both evidence-based practices and inadequately supported practices were in common use in public EI systems. While most participants expressed a desire to use research-based practices, the selection of EI practices seemed to be based more on factors such as marketing, availability of training, and provider and parent preference than on research. According to the authors, "[i]t appeared that if a participant had attended a workshop or lecture on a method, she felt there was sufficient research to support it" (p. 71). Practices that were used were also highly adapted and providers reported being inadequately trained. A positive finding, however, was that most participants reported using the common elements of effective intervention programs mentioned above, with the most commonly endorsed elements being the use of a specialized curriculum (77%) and family involvement (77%) and the least commonly endorsed element being a structured environment (64%). The article points out a need for research on a number of closely related issues including whether procedures should or should not be combined, how procedures should be adapted to individual children, and the fidelity of field implementation of specific methods. The authors also discuss the limitations and the implications of this creative and helpful study, offering the reader a textured and nuanced view of a number of significant issues deserving substantial future consideration by both researchers and policy makers. In sum, this creative and innovative study uses techniques not typically found in the applied behavior analysis literature, makes an important contribution to our current understanding of early intervention practices, points to a number of issues that clearly warrant further research, and merits careful consideration by behavior analysts involved in the development, implementation, and dissemination of behavioral early intervention technology for children with autism. Bob Babcock, Ph.D., BCBA, is the Coordinator of Psychological and Outreach Services for The Learning Tree, Inc. His current activities at TLT include increasing the availability of applied behavior analysis services in community schools for children at risk of referral for residential school services, developing staff training initiatives to promote inclusion and intensive behavioral intervention services for preschool and school-age children with autism and related disabilities, and providing behavioral coaching for adolescents and adults with Asperger's Syndrome and their families.
Carr, J. E., & Firth, A. M. (2005). The verbal behavior approach to early and intensive behavioral intervention for autism: A call for additional empirical support. Journal of Early Intensive Behavioral Intervention, 2(1), 18-27.Reviewed by: Suzannah Ferraioli, B.A. Since the publication of Lovaas' 1987 seminal outcome study on early and intensive behavioral intervention (EIBI), behavioral instructional methodology has been the most widely implemented and evidenced-based treatment for children with autism (McEachin, Smith, & Lovaas, 1993; Smith, 1999). The Lovaas model incorporates discrete-trial instruction, intensive treatment delivery (40 hours per week), and a developmentally sequenced curriculum (Leaf & McEachin, 1999) to create a behavioral treatment that effects positive outcomes in children with autism over a number of years. In response to the recent advent of the verbal behavior (VB) approach, practitioners and consumers requested more services that follow this protocol; consequently, treatment manuals (Sundberg & Partington, 1998) and related assessments (Partington & Sundberg, 1998) are being widely implemented. The authors propose the hierarchy of steps necessary to better establish the efficacy of the VB approach and to justify its dissemination and implementation. Carr and Firth highlight several similarities between the Lovaas and VB models. Firstly, they each stress the importance of environmental control through their utilization of contrived instructional settings, with ready access to salient tangible items and activities to be delivered contingently upon correct responding. Secondly, both approaches teach behavior based upon the expressive/speaker and receptive/listener relationships. Lastly, the Lovaas and VB models deliver instruction and consequences in a discrete-trial instruction format. However, the VB model uses DTI concurrently with Natural Environment Training (NET) while the Lovaas approach uses only DTI. This point highlights a primary difference between the two models, their approach to language training. NET facilitates generalization through a focus on teaching in naturalistic settings as well as under contrived conditions, and by capitalizing on current motivating operations. This contrasts to the systematic, analog environment evoked under the Lovaas model, although generalization may be integrated into instructional programming. In addition, the VB model teaches language using a hierarchy of functions (e.g., mand, tact, intraverbal), and through function-specific motivating variables. Conversely, the Lovaas approach teaches language in discrete steps, without specific regard for the functionally relevant antecedents and consequences. The logic behind the VB approach is empirically based (e.g., Braam & Poling, 1983; Miguel, Carr, & Michael, 2002; Drash, High, & Tudor, 1999). However, this evidence indirectly supports the components behind verbal behavior, rather than the efficacy of the model itself. The authors offer the suggestion that longitudinal outcome studies of the VB model, similar to those conducted for the Lovaas model, may lend more direct evidence for the validity of this treatment. In addition, comparisons between the VB approach and other EIBI methodologies would provide more sound justification for the use of the VB model. To date, one such evaluation has been described by Williams and Greer (1993). The authors compared accuracy and frequency of words used across training trials under VB and linguistic (similar to the Lovaas program) models. The VB curriculum targeted responses based upon the function hierarchy, and the linguistic curriculum sequentially targeted labels, possession and color, and comparative relationships (e.g., size, location). Results showed a similar number of correct trials for participants across curriculum conditions, but the VB sessions elicited higher frequencies and varieties of words, as well as higher rates of correct responding during maintenance probes. This study gives preliminary evidence for the effectiveness of the VB approach; however, the authors reiterate that future replications and longitudinal studies are necessary. Carr and Firth recommend several successive steps for future research in the area of verbal behavior. First, they point to published case studies that focus on the treatment effects elicited by EIBI with a VB basis. These studies would also address the need for long-term evaluations of the VB approach. One such study details a toddler who began EIBI at 1 year, 2 months, and continued the program until 4 years, 5 months (Green, Brennan, & Fein, 2002). His treatment is tracked with regard to changes in curriculum, program intensity, and standardized outcome (e.g., age-equivalent scores). The current authors highlight this last component as another crucial step for the analysis of the VB approach; collateral gains in IQ and age-equivalencies have not yet been documented. Reports modeled after the Green and colleagues case study are a significant step toward sound evidence for the VB model. Another key effort is the publication of outcome data for multiple cases. A comparison of data from a variety of studies would allow for a) an evaluation of the reliability of treatment effects, b) the comparison of treatment effects with published data sets, and c) preliminary correlations between treatment outcomes and potential predictor variables (e.g., comorbid diagnoses, intensity of program supervision). A study by Bibby, Eikeseth, Martin, Mudford, and Reeves (2001) describes the progress of multiple children who received EIBI from their parents. Their analysis of treatment outcomes suggests that children benefited less from this parent-implemented model than those in the Lovass study. Although this predictor variable did not achieve statistical significance, these results indicate that sound treatment fidelity may facilitate better outcomes. The authors express a hope that multiple case studies of the VB approach could produce similar information. Lastly, the authors underscore the need for experimental or quasi-experimental treatment comparisons, a topic on which we touched earlier. This last step would require outcome studies between the VB model and a control condition. Historically, a variety of EIBI methods have been supported through a comparison with a control condition (Lovaas, 1987; Sheinkopf & Siegel, 1998; Smith, Eikeseth, Klevstrand, & Lovaas, 1997). Although the wide dissemination of EIBI strategies may pose a difficulty in finding control groups, standard treatment control groups are evidenced to be an effective basis for comparison (Kazdin, 2003). Additional considerations include the need for subject matching prior to treatment implementation. It is the authors' hope that these control studies will help standardize the procedures of VB in practice and document the outcomes of the VB model on standardized measures. In conclusion, the authors recognize the VB approach as a viable model that deserves further empirical analysis. A systematic progression from case studies to multiple comparisons, and finally to experimental evaluations may provide evidence to justify the widespread implementation of the VB model in a clinical setting. Suzannah Ferraioli is a graduate student in the Department of Psychology at Rutgers University and currently works as a classroom behavioral consultant at the Douglass Developmental Disabilities Center. Her interests include the development of language and joint attention in children with autism and social skills training by typical siblings.
Seligson-Petscher E., & Bailey J. (2006). Effects of training, prompting, and self-monitoring on staff behavior in a classroom for students with disabilities. Journal of Applied Behavioral Analysis, 39, 215-226.Reviewed by: Jennifer L. Buck, M.Ed., Ellsworth, Maine Far too often, paraprofessionals and instructional assistants are not trained to effectively work with students with disabilities. While the typical classroom rules and reprimands may be appropriate for some students, they may not suit the needs of a student with a disability. Uncontrolled and unpredictable behavior exhibited by a student with a disability can interfere not only with the student's ability to learn but may also affect the teacher's ability to teach the student. Therefore, effective staff training and feedback sessions are warranted to train school staff to manage student and classroom behavior. Over the past 8 years, three studies have evaluated the effectiveness of tactile prompts in classroom settings. These studies used vibrating pagers to improve the social initiations and communication skills of children with disabilities (Shabani et al., 2002; Taylor, Hughes, Richard, Hoch, & Coello, 2004; Taylor & Levin, 1998). In contrast to these studies, the current authors explored the effectiveness of tactile prompts in modifying the behavior of instructional staff rather than students. In this study, vibrating pagers were used to increase accurate implementation of a classroom token economy system by instructional staff members. Three female paraprofessionals were selected as participants for the current study. Each instructional assistant had less than one year experience in their current classroom placement. All participants worked in a self-contained classroom for third- to fifth-graders with multiple disabilities (e.g., emotional handicaps, language impairments, Asperger's syndrome, mental handicaps) in need of behavioral support. A token economy was in place for all students, and the tactile prompt intervention used in this study targeted each teacher's management of disruptive behavior using a response cost system, delivery of bonus points to students who were exhibiting appropriate behavior, and prompting students to engage in appropriate behavior when a student was not engaged in the expected activity. The current study used a moving treatments multiple baseline across behaviors design (Bailey & Burch, 2002). Prior to implementation of the intervention, baseline data was collected by observing normal classroom conditions. Participants in this study were aware of the observation but did not know the variables of interest. Observers recorded occurrence or nonoccurrence of the target teacher behavior. Following baseline, all 3 participants attended one training session during which the experimenter described the goals, procedures, dependent variables, and expectations of the classroom token economy system using didactic training and modeling. Each participant took a post-test in which they were asked to identify possible antecedents and appropriate responses to different scenarios. Following this training, data was collected in the classroom as it was collected in baseline until stable responding was observed. Once stability was demonstrated across all participants, the intervention package (prompting, self monitoring and accuracy feedback) was then applied to the first targeted behavior, managing disruptions. The trainer met with participants to discuss and demonstrate the use of the pager and self-monitoring form. Participants were required to clip the pager onto the pants or place it into a pocket. The trainer then explained that she would send participants a tactile prompt via vibrating pager when there was an opportunity to manage a disruption (or, for later target behaviors, deliver a bonus-point or prompt appropriate behavior). Correct and incorrect teacher responses to the student's behavior were recorded. At the end of each 10 minute session (conducted three times per day) the participants were asked to complete a self-monitoring form indicating their perceived performance on the targeted skill during the session. The experimenter assessed the accuracy of the self-monitoring form by comparing observation notes with completed self-monitoring forms. The experimenter then provided the teacher with accuracy feedback on actual performance during the session, as measured during observation, noting any discrepancies between teachers' perceived performance and their actual performance. When teachers exhibited 100% appropriate responding and correct self-monitoring on three consecutive sessions, the prompting layer of the treatment plan was then removed from the first target behavior while self-monitoring and accuracy feedback remained in place. The entire intervention plan was then applied to the next targeted behavior, bonus-point delivery. Once all 3 participants were able to consistently meet the goal for bonus point delivery, the prompting component was removed from the second target behavior (bonus-point delivery) and the full intervention plan was then applied to the last targeted behavior, prompting appropriate behavior. The prompting layer was removed from this behavior when all participants met criteria on prompting appropriate behavior. When a final demonstration of stable responding was observed, the self-monitoring and accuracy feedback layers of the intervention plan were then removed from all three target behaviors and maintenance data was collected. Maintenance sessions gradually increased from 10 minutes to 60 minutes during which data collection still occurred. All 3 participants exhibited dramatic increases in performance of the target behavior following the implementation of the prompting and self-monitoring procedure. While teacher training on the rationale and expectation of the token economy led to variable and low performance among teachers, prompts and self-monitoring led to high, stable performance. This behavior was maintained following the removal of prompting while only self-monitoring remained in place, though for some teachers performance was slightly lower and more variable in this phase. All teachers demonstrated lower and more variable responding in the maintenance phase, though the authors point out that this should be interpreted with caution due to the decreased opportunities for teacher response in the classroom during the maintenance phase. In conclusion, the current research shows that the implementation of tactile prompting and self- monitoring forms show an increase from near-zero levels during baseline and training sessions to consistently high rates after the initial implementation of the intervention package. In addition, high teacher performance levels were maintained with the absence of the prompting layer of the intervention package. It is possible that the prompting procedure was responsible for the overall increase in consistency rather than the self-monitoring procedure. Future studies should include isolation of tactile prompting as an intervention to improve staff behavior. Self-monitoring, however, seemed to maintain skills at a level not seen when it was discontinued in the maintenance phases. Self-monitoring may be an important component for maintenance in teacher performance. From a teacher's perspective, I believe that any teacher, not only those who work with the disabled student, would benefit from this intervention package. References
Jennifer Buck, M.Ed., is a graduate student in the College of Education at the University of Maine and currently works as a Special Educator. Jennifer is also working towards her BCBA and would like to pursue a doctorate in education. Nock, M. K., & Kurtz, S. (2005). Direct behavioral observation in school settings: Bringing science to practice. Cognitive and Behavioral Practice, 12, 359-370.Reviewed by: Nanci Valente, L.D.T.C., M.A., Secaucus Child Study Team, Secaucus, NJ The reauthorization of the Individuals with Disabilities Education Act (IDEA, 2005) mandates that a school observation be a required component of evaluations for students who may exhibit behavior concerns. Further, IDEA recommends that functional behavioral assessments for these students also be carried out as part of the evaluation process. According to the authors of this article, however, a gap exists between strictly formatted, objective assessment procedures detailed in the literature and less structured, subjective methods that are more customarily used to evaluate student behavior in school settings. This paper recognizes the value of conducting an observation of a child in the school setting and provides clinicians with a framework to perform meaningful, valid and research-based evaluations of child behavior in the school environment. School settings provide a structured environment with opportunities to observe and assess children across a variety of domains. Direct observation provides the observer with the opportunity to witness specific behavior, which results in a more precise, descriptive evaluation of target behavior. Observation allows for an assessment of the function of such behavior, as well as the typical frequency and severity measures that could be provided by a rating scale. Such observations are based on direct, objective data, and have the additional advantage of assessing the antecedent and consequences of the behavior episodes (Nock et al, 2004). As behavior analysts would agree, such information is essential to the development of functionally relevant behavior reduction plans. Behavior rating scales have traditionally been utilized to measure possible problem behavior in the classroom. The authors discuss several standardized frameworks that have been developed for assessing behavior. The Classroom Observation Code (COC) discriminates between hyperactive and non-hyperactive children across 14 categories of observation (Abikoff & Gittelman, 1985). The School Observation Coding System (SOCS) and Revised Edition of the School Observation Coding System (REDSOCS) code dimensions of behavior into categories such as appropriate versus inappropriate, compliant versus noncompliant, and off task versus on-task (Jacobs et al, 2000; McNeil et al, 1991). Direct observation coding systems, such as the Direct Observation Form included in the Child Behavior Checklist (CBCL, Achenbach, 1986) and the Student Observation System included in the Behavior Assessment System for Children (Reynolds & Kamphaus, 1998) measure predetermined behavior problems and are meant to supplement teacher-, parent-, and self-report forms. While these measures assess a wide range of behavior exhibited in a natural setting, they lack the specific descriptions that are provided by other observation methods. Further, standard observation formats may not be applicable to the behavior deficits demonstrated by all children, including individuals with autism. If a standard observation format does not appropriately address the behavior of a specific individual, the authors suggest conducting an observation based on the principles of behavioral assessment. Their description of such an assessment follows. The authors propose that a school-based observation offers many advantages such as the ability to assess behavior in a natural, typical environment, which provides a valid and realistic profile of problem behavior. To assist the practitioner in conducting an effective behavioral assessment observation, user-friendly information about identifying, defining and assessing behavior is outlined and discussed in the article. Sample entries for coding behavior are also provided. The authors recommend that the target behavior should be clearly defined, using criteria that are observable and measurable. The description of the target behavior should include a discussion of the events and influences that may contribute to the behavior, as well as the consequences for the behavior. Once the behavior has been clearly defined, direct observation is conducted to assess the occurrence of the behaviors. A variety of methods, such as descriptive format, checklists, frequency recording or interval recordings will provide objective, data-based behavioral assessment. The descriptive method is indicated when specific characteristics and determinants of the behavior are unknown. An objective account of the mechanics of the behavior, its duration and intensity are noted in a descriptive chart format. A checklist method may also be used to record the occurrence of behavior. Checkmarks are coded during the direct observation, which indicate the frequency of the behavior in a time interval, or in a specific environment. Interval methods may be used to code whether a behavior occurred during a specific time interval. Interval recording techniques may also be used to code antecedent-behavior-consequence sequences. Information generated from these methods can be converted to a data-based format for analysis and interpretation. A final note regarding behavioral assessment: While the occurrence of maladaptive behavior may be the reason for a behavioral assessment, the ultimate purpose of an intervention is to provide a replacement behavior. This alternative behavior should be equally specific, and in direct opposition to the problem behavior. The current frequency of a possible replacement behavior (e.g., requests for breaks, tangible items, attention, etc.) should be noted during an observation. The evaluation report framework should be guided by the above noted criteria. The authors suggest a format that delineates the following categories:
This article provides many powerful and important considerations for collecting the information necessary to develop potentially effective treatments. Best practices have emerged which provide the practitioner with an established set of procedures and rules for conducting a systematic behavior analysis and subsequent intervention strategies (Hanley, Iwata & McCord, 2003). Ongoing refinement of environment-based assessments through continued research will continue to strengthen the efficiency and effectiveness of this clinical practice. As many readers are aware, the journal Cognitive and Behavioral Practice is read by psychologists and other professionals who may be more inclined to use a cognitive behavioral versus a behavior analytic approach, and may be more familiar with nomothetic assessment methods versus idiographic assessment methods. Therefore, the publication of this article in such a journal will hopefully encourage and support individuals in the use of assessment methods that are hallmark to applied behavior analysis. References
Nanci Valente is a Learning Disabilities Teacher Consultant for the Secaucus NJ Child Study Team. She is a certified Speech Language Specialist and Special Education Teacher, and has a Masters in Supervision and Administration from Montclair State University. She is currently completing her mentorship experience for BCBA certification.
Rapp, J.T., & Vollmer, T.R. (2005). Stereotypy II: a review of neurobiological interpretations and suggestions for an integration with behavioral methods. Research in Developmental Disabilities, 26, 548-564.
Reviewed by Anna Lewis, B.A. Studies on stereotypic behaviors have been conducted by researchers from either a behavioral or neurobiological perspective. Although the models for stereotypy used by these two groups are not mutually exclusive, there has been little convergence between the two bodies of literature. The divide between behavioral and neurobiological research has widened considerably over the past decade. The authors of this paper strongly advocate the reversal of this trend, highlighting areas in which integrative research holds the greatest promise. They provide an overview of neurobiologically based research on stereotypy over the past few decades, looking first at pharmacological and neurobiological interpretations of stereotypic behaviors, and then at possible pharmacological interventions for such behaviors. Neurobiological researchers have generated several hypotheses regarding the etiology and persistence of repetitive behaviors in nonhumans. This line of research has investigated the effects of environmental deprivation, injections of neurotransmitters, chemically induced lesions, and stress-inducing events on stereotypic behavior. The major point of agreement across research on all of these conditions is that the dopaminergic system plays an important role in the stereotypy of nonhumans, a hypothesis supported by earlier findings that stereotypy can be induced by a dopamine agonist and then reduced by a dopamine antagonist. Unfortunately, the results of many of these studies are difficult to interpret due to methodological issues (i.e., lack of relevant controls). A number of pharmacological interventions have been used to treat stereotypy in developmentally disabled individuals. Much of the literature has examined the effects of serotonin reuptake inhibitors (SSRIs) and opiate agonists. Though antipsychotic medications were once popular choices for the treatment of stereotypy, research on this class of medications has decreased in recent years, due to the potential for development of debilitating side effects, such as tardive dyskinesia. A considerable amount of research has investigated the effects of serotonin reuptake inhibitors on stereotypic behaviors. These medications presumably work by increasing the availability of serotonin in the brain. The results of these studies have been mixed, and again, the results have been difficult to interpret due to limitations in experimental methodology, such as non-replicating treatment designs, variations in dosage of the medication under investigation, subjects concurrently taking other psychoactive medications, and disagreements in ratings between different groups of observers. Opiate antagonists are often considered by researchers as possible treatments for self-injurious behavior (SIB) as well as stereotypic behaviors. The main biological hypotheses for the occurrence of SIB in individuals with developmental disorders involve endogenous opiates - chemicals in the brain that produce euphoric sensations. Some researchers suggest that individuals engage in SIB or stereotypy in order to facilitate the release of endogenous opiates, while others think that the function of SIB/stereotypy is to avoid the effects of opiate withdrawal, or that individuals who exhibit SIB/stereotypy naturally produce excessive levels of endogenous opiates, which blocks pain sensation. Opiate antagonists block endogenous opiates at the receptor cite, preventing the opiates from producing euphoric effects, and are therefore potentially useful in the treatment of SIB and stereotypy. Similar to other pharmacological studies, the effects of opiate antagonists have yielded mixed results (e.g., often not designed to evaluate stereotypy specifically, incomplete designs). Ultimately, the fundamental differences in methodology between pharmacological studies and applied behavioral studies of stereotypy have made it difficult to make inferences between findings in the two literatures. For instance, studies of pharmacological interventions have most often used indirect measurement methods, such as rating scales, to gauge overall changes in multiple response forms, while applied behavioral studies have mainly used direct observations of single response forms. With methodological differences such as these, the same investigation of the same participants using the two approaches could very possibly yield very different results. This is not to suggest that one of the two approaches is better, but rather that different circumstances call for different approaches. For example, it may be best to limit group designs to studies in which each participant exhibits a common response form, as recent studies suggest that different brain regions may be responsible for inducing specific stereotypic response forms in non-humans. At the same time, it would be wise for behavioral studies to add rating scales to their direct observation methods, in order to gauge the social validity of any behavior change that may be produced. In all of these studies, direct observational measures of stereotypy should be emphasized, with clearly operationalized definitions of the behaviors under evaluation. Studies in the future should also explore the possibility of beneficial interactions between pharmacological and behavioral interventions. Several studies have suggested that certain pharmacological treatments seem to change the reinforcing value of specific events, and potential improvements in the outcomes of dual-modality interventions could be achieved by determining the degree to which such a value change takes place in the presence of various dosages of a given drug. Another promising area in which little to no research has been conducted is the effect of behavioral interventions on stereotypy following successful pharmacological intervention. If a given pharmacological intervention decreased stereotypy, it is possible that the right behavioral intervention might maintain this decrease, thereby reducing the need for ongoing use of medication. The authors conclude with the assertion that, while large-scale placebo-controlled studies of pharmacological interventions for stereotypy should continue, research in this area should also incorporate behavioral methods including single-subject experimental designs and differentiated measurement of individual response forms. They also advocate the use of functional analysis and descriptive analysis to identify specific subtypes of stereotypy that may be resistant to environmental manipulation, and thus are cases in which pharmacological interventions are most appropriate. Primarily, however, they advocate a more universal adherence to traditional behavioral standards for response definitions, direct observation, repeated measurement, and experimental controls, in the hopes that more of the research in this area will obtain findings that can be both understood and applied to further work by researchers on both sides of the neurobiological-behavioral divide.
Elder, J.H., Shankar, M.,Shuster, J., Theriaque, D., Burns, S., &Sherrill, L. (2006). The Gluten-Free, Casein-Free diet in autism: Results of a preliminary double blind clinical trial. Journal of Autism and Developmental Disorders, 36 (3), 413 - 420.Reviewed by Jana Horowitz, Psy.M., Rutgers University. The complex and still misunderstood nature of autism often leads individuals to utilize various, treatments, such as the Gluten-Free, Casein-Free (GFCF) diet that have yet to be empirically validated. Anecdotal parent report suggests that children with Autistic Spectrum Disorder (ASD) who follow the GFCF diet demonstrate improvement in language and social skills; however, there is currently a lack of empirical support for these claims. The authors cite preliminary evidence for the benefits of a "structured" diet for children with autism, but explain that previous studies were methodologically limited. In the current study, the researchers randomized 15 children with ASD to either the experimental group, who received the GFCF diet, or the control group, who received a placebo diet (similar, specially prepared meals that were not gluten and casein free). All meals were provided by the investigators. Participants and the investigators were blind as to which subjects were receiving the diet. The dependent variables of interest were measured using the Childhood Autism Rating Scale (CARS), to measure the different symptoms of autism; Urinary Peptide Levels (UPL), to determine the levels of casein and gluten peptides; the Ecological Communication Orientation (ECO) Language Sampling Summary, to examine linguistic skills; and in-home observation, to examine behaviors such as "child initiating, child responding, and intelligible words spoken." The researchers did not find any significant differences between the experimental and the control group on any of the measures utilized to test the dependent variables. However, several parents reported improvement in their children and made the decision to continue with the diet even after the study results were disseminated. The authors point out that their study had several methodological limitations such as a small, heterogeneous sample, potential diet noncompliance, the inability of the CARS to detect subtle behavioral changes and possible placebo effect impacting parent report of the diet's effectiveness. Despite these limitations and the non significant findings, this study presents a well-constructed design that could be utilized by future researchers to test the GFCF and other structured diets.
Codding, R. S., Dunn, E. K., Feinberg, A. B., & Pace, G. M. (2005). Effects of immediate performance feedback on implementation of behavior support plans. Journal of Applied Behavior Analysis, 38, 205-217.
Reviewed by: April Poulsen, M.Ed. The No Child Left Behind Act can be praised for its efforts to further accountability in public school settings. This is consistent with the interest of a number of researchers who are developing and evaluating effective and efficient strategies to promote the integrity of school based interventions. One intervention strategy that has shown to be successful in enhancing treatment integrity is performance feedback (Mortenson & Witt, 1998; Noell et al., 1997, 2000, 2002; Witt et al., 1997). In the literature, several components of performance feedback are often highlighted, including: review of data, reinforcement for accurate/adequate implementation, corrective feedback, and addressing questions or comments. The implementation of academic interventions, such as peer tutoring (Noell et al. 2000), contingent praise (Jones, Wickstrom, & Friman, 1997, Martens, Hiralall, & Bradley, 1997), and implementation of behavior management interventions, more specifically data collection (Noell et al. 2002) has already been targeted for improvement via performance feedback. In the current study, Codding, Dunn, Feinberg, & Pace (2005) also examined the effects of performance feedback on data collection; however, it was noted by the authors that Noell and colleagues used performance feedback to address only one aspect of behavior management: data collection. Although reliable data collection is essential, the current study extended the existing literature by examining two other aspects of plan implementation: 1) Implementation of antecedent interventions to decrease the likelihood of problem behavior; and 2) Implementation of consequences. As a special education teacher, I can appreciate the need for these two areas to be examined more closely within the literature. The participants in this study were five special education teachers who worked in a private school for students with acquired brain injury, with between 6-30 months experience working at this school. All of the teachers had bachelor degrees and were enrolled in masters degree programs in special education. It is important to note that the participating teachers had both general and student specific formal training in the implementation of behavioral support plans. As will be discussed later, these experiences may put some constraints on the generalizability of these findings. Each teacher was paired with a male student between the ages of 10-19 years old with acquired brain injury (3 with non-traumatic, 2 with traumatic brain injury) who exhibited significant behavior problems. This student sample represented about 10% of the school population. Teacher-student dyads were observed for approximately 60 minutes, every two weeks on a variable-interval schedule, within a classroom setting (two teacher-student dyads were in Classroom 1 and three teacher-student dyads were in Classroom 2). Baseline observations were conducted until stable or decreasing performance in baseline was demonstrated by either the percentage of antecedent or consequence components implemented as written. On the same day as each observation, the experimenter met with the teacher for an average of twelve minutes, outside of the classroom. During this time, behavior support plans were reviewed and feedback was provided for all components that were observed. Performance feedback was ended after improved performance was stabilized and 1-3 maintenance sessions (identical to baseline) were conducted with 5 week intervals, for each dyad. Overall results of the study demonstrated that the accuracy with which a behavior plan was implemented improved across all five teacher-student dyads following performance feedback. In addition, results of the performance feedback were maintained for up to 15 weeks after the study was completed. There were, however, some differences noted in the amount of improvement of antecedents versus consequence components between the two classrooms. Classroom 2 showed a greater improvement for antecedent interventions following feedback than the two dyads in Classroom 1. The authors noted that antecedent procedures may have operated as a part of the daily classroom routine in Classroom 2 and therefore affected the implementation of antecedent components to a greater degree. The results of this study suggest that performance feedback is an acceptable and effective intervention for improving the treatment integrity of special education teachers' administration of antecedent and consequence components of behavior support plans. There are however, a number of factors that may influence the effectiveness of performance feedback and warrant future study. Some of these possible directions include: the social validity of performance feedback for teachers, how a teacher's active role in developing support plans affects their implementation of such plans, and the role and effect of previous instruction and training in support plan implementation. On a more practical note, the article appendix contains a copy of the Integrity Assessment for Behavior Support Plans. I found this checklist to be very useful and will be using it with my staff this upcoming school year. References
Sallows, G. O., & Graupner, T. D. (2005). Intensive Behavioral Treatment for Children with Autism: Four-Year Outcome and Predictors. American Journal on Mental Retardation, 110 (2), 417-438.Reviewed by: Lara Delmolino, Ph.D., BCBA, & Karen Lenard, MS.Ed., BCBA Douglass Developmental Disabilities Center, Rutgers University The evidence that intensive early behavioral intervention is an effective intervention originated with the Lovaas study, published in 1987. That study showed dramatic improvements in the experimental group with post treatment scores increasing to the average range. However subsequent attempts to replicate these results were not as striking, casting doubt on the importance of Lovaas' findings. Sallows and Graupner (2005) sought to replicate the UCLA results without the use of aversive stimuli and including additional behavioral techniques that have demonstrated effectiveness. The researchers compared outcomes between a clinic-directed group, providing the supervision and intensity of treatment hours in the UCLA study with and a parent-directed group, in which supervision was lower and parents selected the intensity of treatment hours they wanted. Twenty-four participants (nineteen boys and four girls) participated in the study. Participants began treatment between 35 and 37 months of age, with treatment lasting for up to four years. All children met the criteria for autism as outlined in the DSM-IV and in the Autism Diagnostic Interview - Revised (ADI-R). Children were randomly assigned to either the clinic-directed group or the parent-directed group, which was intended to be less intensive. The actual weekly means of direct treatment differed by about 7 hours, 39 for the clinic-directed and 32 for the parent directed group during the first two years. The clinic-directed group received approximately 6-8 hours per week of supervision and weekly review by a clinic supervisor, while the parent-directed group received 6 hours per month of supervision by a senior therapist and review every other month by a clinic supervisor. To evaluate pre-treatment levels of performance and post-treatment gains, measures included instruments to assess IQ, language, adaptive behavior, and early learning rates, including: Bayley Scales of Infant Development, 2nd edition, Merrill-Palmer Scale of Mental Tests, Reynell Developmental Language Scales, and Vineland Adaptive Behavior Scales. Follow-up tests administered annually included IQ - Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI), or the Wechsler Intelligence Scale for Children (WISC-II), or the Bayley II, and the Leiter-R. Language tests included the Clinical Evaluation of Language Fundamentals, 3rd edition (CELF III) or the Reynell Developmental Language Scales. The Vineland Adaptive Behavior Scales was re-administered to all children. Post-treatment social, behavioral, and adaptive functioning was measured using the Autism Diagnostic Interview-Revised (ADI-R), the Personality Inventory for Children (PIC), the Child Behavior Checklist (CBC), and both parent and teacher Vineland scores. When the children reached seven years of age, academic functioning was measured using the Woodcock-Johnson II Test of Achievement. Treatment curriculum included that described by Lovaas minus the aversive procedures and additionally including procedures supported by more recent research. Learning sessions initially began at 30 seconds in length and were interspersed with playful interactions with therapists/parents to increase compliance and social responsiveness as well as to teach generalization of new skills in less structured settings. RESULTS Of the 11 rapid learners, 5 received services in the clinic-directed model and 6 participated in the parent-directed model. The clinic-directed rapid learners were found to have higher pre-treatment IQ's, Vineland Scores and Verbal Imitation abilities than those in the parent-directed group, which prevented the planned comparison between rapid learners in the clinic-directed and parent-directed groups. Regression analyses were used to identify pretreatment predictors of outcome. The authors found that post treatment IQ was best predicted by the Early Learning measure, pretreatment IQ, and ADI-R communication and social interaction scores. Additionally, acquisition of social skills and language skills were predicted by pretreatment ability to imitate. Change after one year was also a strong predictor of outcome. Although absence of expressive language (at 36 months) was associated with more moderate learning, regression of speech was not. Lastly, the number of hours of treatment each week was less related to outcome measures than were pretreatment measures. Overall, the study demonstrated that the UCLA model of intensive intervention could be replicated outside of a university setting, utilizing both clinic-directed and parent-directed treatment models, with all children demonstrating improvement across skill areas over four years of treatment. Further, and consistent with Lovaas' 1987 study, 48% of the 23 children receiving treatment made large gains with post treatment IQ, language, and socialization scores in the average range and effective participation in regular education after four years. The present study offered confirmatory evidence of Lovaas' 1987 finding that nearly half of the children receiving intensive behavioral intervention could achieve average functioning.
Reynout, G., & Carter, M. (2009). The use of Social Stories by teachers and their perceived efficacy. Research in Autism Spectrum Disorders. (3) 232 – 251. By: David J. Cox, M.S.B. Assistant Clinical Director
Creative Perspectives Inc., Autism Centers of Colorado
Background
Carol Gray defines a Social StoryTM as a story that describes a situation, skill, or concept in terms of the relevant social cues, perspectives, and common responses in a specifically designed style and format. The aim being to share needed and accurate information about a social situation in a manner that can be easily understood by the targeted individual(s) the story has been written for. Although there have been several recent literature reviews have examined empirical research on Social Stories (Ali & Frederickson, 2006; Reynhout & Carter, 2006; Rust & Smith, 2006; Sansosti, Powell-Smith, & Kincaid, 2004), there remains a need for information on the application of Social Stories as an intervention including data analysis pertaining to: study participants, consistent construction and implementation of Social Stories across studies, the use of Social Stories independent from other interventions, greater analysis amongst intervention areas, maintenance and generalization of learned skills, and actual implementation by practitioners within the school setting.
It is the final area of a current lacking of research that this article attempts to increase the research base surrounding the use of Social Stories as intervention. Specifically it attempted to determine the following four items: “(1) the characteristics of children with whom Social Stories are used, how extensively they employed and the types of behaviors are targeted by teachers; (2) how and why teachers use Social Stories (including the extent to which Social Stories conform to recommended construction); (3) teacher’s perceived acceptability, applicability and efficacy of Social Stories; and (4) how perceived efficacy varies across student characteristics, story construction and implementation characteristics.”
Method
A questionnaire was constructed that consisted of four parts: (1) teacher demographics and background information; (2) how and why teachers use Social Stories; (3) teacher’s opinions of Social Stories in relation to acceptability, appropriateness and efficacy; and (4) a request for teachers to photocopy and provide the researchers the two most recent examples of Social Stories they had used with students. Six schools from Autism Spectrum Australia and five Catholic Special Schools were approached and agreed to participate. A total of 105 questionnaires were distributed.
Each sample story provided by teachers was coded for the frequency of various sentence types outlined by Gray (2000). These included descriptive, perspectives, affirmative, directive, control, and cooperative. The ratios and types of sentences were also coded to determine if they fit into Gray’s definition of “basic” or “complete” Social Stories and whether Social Stories that did not fit the “basic” or “complete” criteria were “appropriately modified” or “inappropriately modified”. Reliability was trained using the first six stories that were received that contained sentences and IOA was calculated for a random set of 18 stories after reliability had been trained. IOA percentages were 85.5%, 82.9%, 50%, 86.2%, 80%, 83.3%, and 96.9% for descriptive sentences, perspectives sentences, affirmative sentences, directive sentences, cooperative sentences, consequence sentences, and whose perspective was taken respectively.
Results
There was a 43% return rate achieved for the questionnaires and 81 sample Social Stories were obtained with respondents being mainly female (89%), working with infants/primary-aged children (67%), possessing over 9 years teaching in special education (42%), having formal qualification in special education (58%), and having received Social Story training (71%).
Teachers reported that the main reasons they utilized Social Stories was to target social skills (91%), reduce inappropriate behaviors (91%), and to introduce changes/new routines (87%). Teachers also reported as using them across a variety of settings including the classroom (100%) and settings related to community access (29%). Many teachers reported collecting data before (78%), during (49%), and after (58%) intervention, however, the reliability and validity of the data collection was not ascertained.
Only 4% of the teachers reported that they always adhere to Gray’s (2000) guidelines regarding Social Story construction and 36% did not know whether they adhered to the guidelines or not. All of the teachers reported that they always (60%) or sometimes (40%) used Social Stories in conjunction with other interventions and 85% of the teachers reported that they always (36%) or sometimes (49%) included a comprehension session as a component of the intervention. Systematic fading of the Social Story was reported as occurring with 73% of the teachers and 80% reported they always (13%) or sometimes (67%) attempted generalization with Social Stories.
The teachers indicated that they generally use Social Stories as an intervention because they are easy to construct and implement and believe them to be effective despite a wide ranging perception of issues surrounding maintenance and generalization. In addition, the cognitive ability and expressive language skills of the targeted individual appeared to affect the perceived efficacy of Social Stories as an intervention whereas the receptive language skills of the individual and their level of autism did not appear to affect the perceived efficacy of the intervention. The sample stories ranged in the age of the targeted individual (17 years old), the level of autism (non-autistic to severely autistic), level of cognitive impairment (above average to severe cognitive impairment), and across more than one setting. In addition, teachers reported writing on average 1-25 stories a year.
Finally, when coded in relation to the format described by Gray (2000), 20% of the sample were “basic” Social Stories, 0% were “complete” Social Stories, 14% were appropriately modified, 59% were inappropriately modified, and 7% were not able to be coded. This indicates that the Social Stories provided by teachers regularly departed from the guidelines recommended by Gray (2000). Interestingly enough those stories that deviated from recommended story construction were rated as more efficacious that those that did not.
Limitations
Overall the limitations stem mainly from the fact that the study was conducted using a survey method for data collection and analysis. Overall the response rate was low, there was no way to check the accuracy of the responses, and the sample of the stories received was not an accurate representation of all of the stories written by the teachers as it only requested the last two stories written by the teachers rather than reviewing all stories written by the participating teachers.
Davis, T.N., Durand, S., & Chan, J.M. (2011). The effects of a brushing procedure on stereotypical behavior. Research in Autism Spectrum Disorders. (5) 1053 – 1058.Written by David J. Cox, M.S.B. Research Director, Autism Interdisciplinary Research Institute & Assistant Clinical Director Creative Perspectives Inc., Autism Centers of Colorado Background The presence of stereotyped behaviors, defined as repetitive behaviors that serve no apparent adaptive purpose , are one of the most debilitating core characteristics of individuals with autism spectrum disorders. This stems from the significant portion of an individual’s behavioral repertoire stereotyped behavior consumes leading to interference in the acquisition of many adaptive behaviors and the simultaneous inability to partake in many naturally occurring learning opportunities and increasing the probability of social isolation . The result is a tremendous need for successful and efficient treatment programs for stereotyped behaviors. Due to the more-often-than-not conclusion that stereotypical behavior is automatically reinforced through stimulation of one of the five types of sensory receptors (mechanoreceptors, chemoreceptors, nociceptors, thermoreceptors, and/or electromagnetic receptors) sensory integration therapy is often implemented with children with autism (38% of parents reporting that they currently receive sensory integration therapy and another 33% report having received it in the past) . The premise behind sensory integration therapy is that individuals with autism are engaging in stereotypical behaviors in attempts to seek preferred sensory stimuli and avoid averse sensory stimuli in order to create homeostasis within the sensory nervous system . One common sensory integration technique originated by Ayers in the 1960s is known as the Wilbarger Protocol and involves firmly brushing an individual’s arms, hands, back, legs, and feet with a soft surgical brush often followed by gentle compressions to the shoulders, elbows, wrists, hips, knees, ankles, fingers, and feet . The brushing protocol is recommended for individuals between the ages of 2-12 years, administered every 90-120 minutes, and hands-on training is highly insisted upon as the “procedure cannot be conveyed in written form” . The current use of the Wilbarger Protocol varies from the original purpose of treating overreaction and avoidance of a sensation from any sensory modality to its current use to treat a variety of disorders and disabilities and to target a variety of skills and behaviors including stereotypy. The brushing protocol is widely used by many individuals as evidenced from the more than 20,000 therapeutic brushes that are ordered each year and with more than 15,000 health care professionals having received the specialized Wilbarger Protocol training . In addition, a survey conducted by Sudore reported that 78% of occupational therapists surveyed use the Wilbarger Protocol with only 2.6% of the respondents reporting a concern over the lack of evidence supporting the effectiveness of the protocol. The few studies that have examined the effects of brushing consist of case studies and clinical reports without experimental designs and often use the protocol as a single component of multi-component treatment programs resulting in the inability to examine the effectiveness of the brushing protocol independently . The purpose of the present study was to examine the effects of a brushing protocol on the stereotypy of a 4 year old boy with autism as carried out by his mother and one-to-one therapist whom received the hands-on training in the protocol. Method The participant was a 4 year old Caucasian male from a two-parent home with two siblings, and who had received the diagnosis of autism when he was 2 years old. He did not attend school and received 40 hours a week of one-to-one in-home behavioral therapy per week and was non-verbal, communicating using gestures to request preferred objects. Three topographies of stereotypical behavior were identified via direct observation: hand flapping, finger flicking, and body rocking. Data collection and all portions of the study occurred in the participant’s bedroom which was not altered in any way, included a bed and several toys stored away, and the door remained closed such that his siblings and mother were not in sight but could be heard from the other rooms. A functional analysis was conducted prior to the experimental phases and utilized five assessment conditions: attention, demand, tangible, play, and alone with each condition lasting 5 minutes and the sequence of conditions was counterbalanced prior to the assessment. An ABA design was implemented for the experimental phases and included taking data across a 1 week baseline, weeks 3 and 5 of implementation of the brushing protocol, and 6 months after the discontinuation of the brushing protocol. Data were collected on a 10 s partial-interval procedure and a percent of intervals in which stereotypical behavior occurred was calculated. Interobserver agreement was conducted on 33% of FA sessions and 55% of treatment sessions with a mean IOA of 97% (range 93-100%) for the FA and 96% (range 80-100%) for the treatment sessions. The participant engaged in fine motor activities during each observation session. During baseline and return to baseline no brushing was provided to the participant. During the intervention condition, the participant was brushed seven times per day evenly spaced among waking hours using a brush recommended by the occupational therapist as being the correct brush for the Wilbarger Protocol. The participant’s mother predominantly brushed him using long strokes and firm pressure on his arms, hands, back, legs, and feet until the entire skin surface was brushed, with 3-10 brushes per body part with the participant’s in-home therapist brushing him when the mother was unavailable. Results The results of the FA concluded that the participant’s stereotypy was relatively high across all conditions. However, information gathered in previous observations led the authors to conclude that the elevated finger flicking across conditions and the high levels of stereotypy in the alone condition suggest that the participant’s stereotypy may have been maintained by access to automatic reinforcement. The results of the brushing protocol demonstrated overlapping data points between each of the phases of the study as well as an overall lacking of marked and consistent distinction between brushing and non-brushing phases suggesting that brushing did not have an effect on the participant’s stereotypical behaviors. In addition, there were slightly elevated levels of stereotypy and an upward trend observed during each of the intervention weeks that data was taken. Discussion The introduction of the Wilbarger Protocol did not lead to any noticeable decrease in stereotypical behaviors for this 4 year old boy with autism. However the authors note two possible explanations for the results obtained. First, it is possible that the brushing did not provide enough sensory stimulation to override the participant’s desire to engage in the stereotypical behaviors as the mechanism behind sensory integration therapy suggests. Second, the sensory input provided by the brushing may not have been the sensory input the participant attains through the stereotyped behaviors he engages in. No explanation was offered for rationale behind the slightly elevated levels of stereotypy observed during the intervention phases and two limitations to the study were also offered by the authors. First, the use of an ABAB design would have been ideal but the parents wished not to reinstate the brushing protocol due to the lack of positive effects from the first treatment condition. Second, treatment fidelity was not collected on implementation of the Wilbarger Protocol. 96 800x600 Normal 0 false false false EN-US JA X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman";} McPheeters, M. L., Warren, Z., Sathe, N., Bruzek, J. L., Krishnaswami, S., Jerome, R. N., & Veenstra-VanderWeele, J. (2011). A systematic review of medical treatments for children with autism spectrum disorders. Pediatrics, 127, e1312-e1321. published online, April 4, 2011.Reviewed by Jonathan W. Kimball, Ph.D., BCBA-D
This review of “medical treatments” for children with autism may be of interest to members of the Special Interest Group on at least two levels: first, for the information that it provides about empirically supported medical treatments for children with autism; second, for what it suggests about the nature of evidence based practice with respect to medication/medical interventions.
For the purposes of McPheeters et al.’s review, medical treatments comprise a narrowly defined set, consisting primarily of “the administration of external substances to the body to treat symptoms of ASD” (Agency for Healthcare Research and Quality [AHRQ] Executive Summary, 2011, p. 2). In addition to pharmacologic agents, which are ancillary treatments that expressly do not target the core symptoms of autism, other interventions grouped under the medical heading include “modalities such as therapeutic diets, supplements, hormonal supplements, immunoglobulin, hyperbaric oxygen, and chelating agents” (AHRQ, p. 2), but in most cases evidence for their use is lacking or, as in the case of secretin, indicates lack of efficacy that warrants no further study (AHRQ, pp. 8-9). It must also be noted that McPheeters et al.’s review is just one small tip of a very large iceberg, a report called Therapies for children with autism spectrum disorders (Warren, Veenstra-VanderWeele, et al., 2011), produced by the Effective Health Care Program operated by the AHRQ (part of the U.S. Department of Health and Human Services). Incidentally, another product of this project that will also be of interest to readers is A systematic review of early intensive intervention for autism spectrum disorders (Warren, McPheeters, Sathe, Foss-Feig, Glasser, & Veenstra-VanderWeele, 2011).
McPheeters et al. include a graphic showing that 4120 articles published between 2000 and May 2010, concerning children aged 2 to 12, were originally produced by searches of MEDLINE, PsychINFO, and ERIC, as well as hand searches of reference lists from the yield. A nearly identical graphic appears in the AHRQ Executive Summary: 4120, it turns out, is the number of articles produced by the larger search of all therapies, including behavioral, educational, allied health (e.g., speech, occupational, and physical therapies), and complementary and alternative medicine (of which the executive summary provides only two examples: acupuncture and massage). The AHRQ full report winnowed the original 4120 articles down to 183 articles; of these, a mere 18 provide the evidence base for medical treatments.
Criteria for the original search of articles, in addition to age range and year of publication (2000 was when the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders was published), included all experimental designs and stipulated that studies of medical treatments include a minimum of 30 participants. Articles thus identified were subsequently evaluated in a two-step process to ultimately determine what, if any, practices could be deemed evidence-based (for a helpful elucidation of evidence based practice, see Luiselli, Russo, Christian, & Wilczynski, 2008, section 1). First, two independent reviewers assessed the pool of studies for “quality,” using an algorithm that rated study design, diagnostic approach, participant ascertainment and characterization, intervention description, outcomes measurement, and statistical analysis (the algorithm is available in the full report, Warren et al., 2011). This is the assessment that yielded 18 studies considered to be of satisfactory quality to then serve as a basis for determination of “strength of evidence.” Nine of the studies—including 7 randomized controlled trials (RCTs)—were concerned with antipsychotic medications (risperidone, 6; aripiprazole, 2, both sponsored by the manufacturer; and haloperidol, with and without cyproheptadine, 1). Five studies—2 RCTs—examined a number of serotonin reuptake inhibitors (SRIs), and 4 studies—1 RCT—examined psychostimulants.
McPheeters et al. gauged strength of evidence with a 4-part rubric described in Owens et al. (2010). Specifically, they assessed the following: Risk of bias – “Reflects issues in study design and conduct that could result in biased estimates of effect” (McPheeters et al., 2011, p. e1314, Table 2); Consistency – “Reflects similarity of effect sizes seen across studies; consistency cannot be assessed when only 1 study is available” (McPheeters et al., 2011, p. e1314, Table 2); Directness – “Reflects the relationship between the intervention and the ultimate health outcome of interest” (McPheeters et al., 2011, p. e1314, Table 2); and Precision – Reflects the level of certainty around the effect observed” (McPheeters et al., 2011, p. e1314, Table 2).
McPheeters et al.’s analysis reached the following conclusions for respective classes of medication: Antipsyhotics – “We rated the strength of evidence for the effect on challenging and repetitive behaviors to be moderate for risperidone and high for aripiprazole, which means that future research is unlikely to change our assessment of the benefit of these antipsychotic medications. Both medications also cause significant adverse effects including marked weight gain, sedation, and risk of extrapyramidal symptoms…that limit their use to patients with severe impairment or risk of injury” (p. e1318). SRIs – “With only 1 good quality RCT available and an additional RCT of fair quality, we consider the strength of evidence for the ability of SRI medications to reduce repetitive or challenging behavior to be insufficient” (p. e1318). Stimulants – The strength of evidence for the effect of stimulants on hyperactivity and challenging behavior was also insufficient on the basis of 1 good-quality RCT” (p. e1318).
The paper concludes by offering suggestions for future directions, including: “Some of the strongest study results to support the use of medical interventions have been funded by pharmaceutical companies or device manufacturers that profit from the treatment. The National Institutes of Health have funded 2 published large-scale studies of medical interventions, but more publicly funded studies of medications for ASDs are warranted” (p. e1318). “Dosing information remains inadequate in the stimulant literature and is particularly important for balancing positive outcomes with potential harms” (p. e1318). “The data on SRIs are scattered and contradictory, and there is a particular need to consider modifiers such as age and pharmacogenetics” (pp. e1318-e1319). “A number of medical treatments have been evaluated in single studies or in small sample sizes that did not meet criteria for our review, and larger well-controlled studies are necessary to evaluate their potential benefit” (p. e1319). “On the basis of available evidence, new treatments are urgently needed to treat both core symptoms and associated symptoms in patients with ASDs” (p. e1319). “Finally, this literature lacks comparisons of medical interventions with behavioral interventions and combinations of the 2, despite the fact that most children are undergoing multiple concurrent treatments” (p. e1319). The final sentence of this paper makes the papers most critical point: Apart from research conducted with risperidone and aripiprazole (which themselves are limited in what they treat and when or with whom they might be used), “Insufficient evidence is available to judge the potential benefit or adverse effects of all other medical interventions used to treat autism” (p. e1319).
This article, whether or not it intends to, exposes the challenge of “evidence based practice.” When reasonably stringent criteria for quality of research and strength of evidence are applied to so few studies, clear conclusions regarding efficacy are difficult to obtain. : In the authors’ own words, “Although many children with ASDs are currently treated with medical interventions, strikingly little evidence exists to support clear benefit for most medications” (p. e1318). With such a startling disconnect between scant research demonstrating efficacy and the pervasive use of such medications, it is critical that reviews such as this raise the issue of the need for additional study.
References
Agency for Healthcare Research and Quality. (2011). Therapies for children with autism spectrum disorders: Executive summary. Retrieved December 3, 2011 from http://www.effectivehealthcare.ahrq.gov/ehc/products/106/651/Autism_Disorder_exec-summ.pdf,.
Luiselli, J. K., Russo, D. C., Christian, W. P., & Wilczynski, S. M. (Eds.). (2008). Effective practices for children with autism: Educational and behavioral support interventions that work. New York: Oxford University Press. Owens, D. K., Lohr, K. N., Atkins, D., Treadwell, J. R., Reston, J. T., Bass, E. B., Chang, S., & Helfand, M. (2010, May). AHRQ series paper 5: Grading the strength of a body of evidence when comparing medical interventions: Agency for healthcare research and quality and the effective health-care program. Journal of clinical epidemiology,63, 513-523. Romanczyk, R. G., & Gillis, J. M. (2008). Practice guidelines for autism education and intervention: Historical perspective and recent developments. In J. K. Luiselli, D. C. Russo, W. P. Christian, & S. M. Wilczynski (Eds.), Effective practices for children with autism: Educational and behavioral support interventions that work (pp. 27-36). New York: Oxford University Press Warren, Z., McPheeters, M. L., Sathe, N., Foss-Feig, J. H., Glasser, A., & Veenstra-VanderWeele, J. (2011, April). A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics, 127, e1303-1311. Abstract retrieved December 3, 2011 from http://pediatrics.aappublications.org/content/early/2011/04/04/peds.2011-0426.abstract. Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J. H., et al. (2011). Therapies for children with autism spectrum disorders. Comparative effectiveness review 26. AHRQ Publication 11-EHC035-EF. Rockville, MD: Agency for Healthcare Research and Quality.
Normal 0 false false false EN-US JA X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin-top:0in; mso-para-margin-right:0in; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0in; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:Calibri; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin;} 17. Najdowski, A. C., Wallace, M. D., Reagon, K., Penrod, B., Higbee, T. S., & Tarbox, J. (2010). Utilizing a home-based parent training approach in the treatment of food selectivity. Behavioral Interventions, 25(2), 89-107.Reviewed by: Taira M. Lanagan, MS, BCBA, FirstSteps for Kids, Inc. It is estimated that approximately 25-35% of typically developing children (Burklow, Phelps, Schultz, McConnell, & Rudolph, 1998) and up to 74% of children with developmental disabilities display some level of feeding problems (Ledford & Gast, 2006). Pediatric feeding problems can include food selectivity, by type (e.g., a diet consisting of mostly carbohydrates), texture (e.g., consuming only baby food), or presentation (e.g., only consuming foods presented on a specific plate or cup). Feeding problems can also include food refusal, either in part or completely. There is ample empirical support for the use of behavior analytic interventions to effectively treat feeding problems for children with and without developmental disabilities (e.g., Piazza, Patel, Gulotta, Sevin, & Layer, 2003; Reed, Piazza, Patel, Layer, Bachmeyer, Bethke, & Gutshall, 2004; Riordan, Iwata, Finney, Wohl, & Stanley, 1984), as well as research specific to children with autism (e.g., Laud, Girolami, Boscoe, & Gulotta, 2009; Sharp & Jaquess, 2009). The purpose of the current study was to teach parents to implement behavioral feeding interventions in their homes, with only consultative supervision. Participants included three child-parent dyads of which all three children exhibited a limited variety of foods consumed (i.e., fewer than 12) and engaged in inappropriate mealtime behaviors when presented with novel or non-preferred foods. Two of the three children were diagnosed with autism; the third was typically developing. All sessions were implemented by the child’s mother in the home environment, 2-7 days per week, one meal per day. Clinicians were present for one meal per week and mothers implemented the remainder of sessions without direct supervision.
Data were collected on both child and parent behaviors across all phases of the study. For the three children, data were collected for each bite on acceptance and swallow, as well as occurrence/non-occurrence of inappropriate mealtime behaviors for that bite. Parent data were collected on integrity of implementation of prompting procedures, consequences presented following inappropriate mealtime behaviors, consequences presented following acceptance and/or swallows, non-removal of the spoon, representation of expelled bites, ignoring other inappropriate behaviors, prevention of escape, and consequences presented following consumption of the bite requirement.
A multiple baseline was used across participants. During baseline, the mothers presented non-preferred foods using 3-step guided compliance (i.e., vocal, gestural, physical) each child received praise and one bite of a highly preferred food contingent on acceptance of a non-preferred food. Treatment included non-removal of the spoon (i.e., if the child did not self-feed presented bite within 5 seconds of presentation, the bite was held in front of mouth until it was accepted), reinforcement for accepted and swallowed bites, and demand fading (i.e., the bite requirement was systematically increased).
None of the three children swallowed any bites during baseline. Upon introduction of the treatment package, all three children accepted bites of non-preferred foods, but did not swallow the bites. However, following 4-7 sessions of exposure to intervention, swallows increased and stabilized to 100% across all three participants. Additionally, inappropriate mealtime behaviors decreased across all participants.
This study has several implications. Firstly, results indicate that it is possible to effectively treat feeding problems, for some individuals, in the home environment. Home-based treatment may be favorable for many reasons, including programming for generalization, saving possible stress to the child and family, as well as being a cost effective treatment option. In addition, this study serves as evidence for utilizing parents and caregivers as behavior change agents. Parent implementation of behavioral strategies, including feeding interventions, is crucial to ensure behavioral maintenance.
Burklow, K. A., Phelps, A. N., Schultz, J. R., McConnell, K., & Rudolph, C. (1998). Classifying complex pediatric feeding disorders. Journal of Pediatric Gastroenterology and Nutrition, 27, 143-147. Laud, R. B., Girolami, P. A., Boscoe, J. H., & Gulotta, C. S. (2009). Treatment outcomes for severe feeding problems in children with autism spectrum disorder. Behavior Modification, 33(5), 520-536. Ledford, J. R., & Gast, D. L. (2006). Feeding problems in children with autism spectrum disorders: a review. Focus on Autism and Other Developmental Disabilities, 21, 153–166.
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324. Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Bachmeyer, M. H., Bethke, S. D., & Gutshall, K. A. (2004). On the relative contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal. Journal Of Applied Behavior Analysis, 37(1), 24-42. Riordan, M. M., Iwata, B. A., Finney, J. W., Wohl, M. K., & Stanley, A. E. (1984). Behavioral assessment and treatment of chronic food refusal in handicapped children. Journal of Applied Behavior Analysis, 17, 327-341. Sharp, W. G., & Jaquess, D. L. (2009). Bite size and texture assessments to prescribe treatment for severe food selectivity in autism. Behavioral Interventions, 24(3), 157-170. Normal 0 false false false EN-US JA X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; font-family:Cambria;} Science, Fads and Applied Behavior Analysis: Autism Service DogsNormal 0 false false false EN-US JA X-NONE Thomas Zane, Ph.D., BCBA-D
There is a long history of animals being used to provide unique services for individuals who need specialized assistance in some way. For example, are trained to provide assistance to persons with visual impairments to negotiate the physical environment. In addition to providing such basic services of security and protection, animals have been used to provide emotional and psychological comfort and support to people (e.g., Hall & Malpus, 2000). In fact, it has been experimentally shown that social interactions can increase simply by being in the presence of a dog McNicholas & Collis,2 000. The increasing incidence of autism spectrum disorders has resulted in an increase in therapies designed to treat this condition. A recent development has been the training of dogs to specialize in working with persons with autism spectrum disorders. Proponents of “autism dogs” assert that these dogs can support the unique challenges of persons on the spectrum. This article reviews the current knowledge and research in this area. An “autism dog” is a dog that is trained to be with a person with autism, usually connected physically with ropes or other forms of tethers. There are two primary objectives for such dogs. First and foremost, they are considered “service” dogs. According to National Service Dogs (2011), the mission of these animals is to increase the safety of the person with autism. For example, such dogs may lower the likelihood of bolting (elopement) or crossing a busy street, due to the dog being physically connected to the person with autism by tethers or ropes (Autism Service Dogs, 2011). The dogs are trained to follow commands from parents, stop at doorways, and resist the child moving away by using its weight to slow or stop the child (e.g., Burrows, Adams, & Millman, 2008a; Burrows, Adams, & Spiers, 2008b). Dogs also have been known to alert parents of potentially dangerous situations at night (e.g., child waking up and walking around, or is unhappy). This can result in not only the person with autism remaining safe from harm, but also parents and other family members being calmer, happier, and more relaxed knowing that the safety issue is less of a concern. One difference between autism service dogs and other service dogs is that typically, service dogs are trained to bond primarily with the person whom the dog will be helping. However, autism service dogs are trained to primarily bond with and take instructions from the parent(s), but trained to work with the person with autism (Burrows, et al., 2008a). Some proponents assert that such dogs do more than enhance physical safety. Some (e.g., Autism Service Dogs of America, 2011) argue that the dogs provide a “calming presence” that “can minimize and often eliminate emotional outbursts.” Some advocates believe that such dogs can provide “…. a focus through which the child can interact with other children. This helps increase the opportunity for the child to develop social and language skills.” Burrows, et al. (2008a) believed that dogs can positively influence children with autism in the areas of arousal and sensory stimulation, improving concerns in these areas. In addition, dogs can function as a “transitional object,” allowing the child with autism to first bond with the dog, an easier creature with which to do so, and this may eventually increase bonding with humans. To obtain a dog, parents must apply to one of the organizations that supply these animals (e.g., 4 Paws for Ability; Autism Service Dogs of America; National Service Dogs). The cost is approximately $20,000. The prerequisites for a child to obtain such a trained dog seems unspecified. There appears to be no exclusionary criteria for either the diagnosis of autism (autistic, asperger, PDD – NOS) or the age. The organization, 4 Paws for Ability (http://www.4pawsforability.org) specifically states that age or severity of disability does not exclude one from getting a dog. On the website for the Autism Service Dogs for America (http://autismservicedogs.com), the application does not focus much on the functioning level of the target child. Several question are asked as to the type of problem behaviors exhibited by the person who will receive the dog (e.g., oversensitivity to sound, self-injurious behavior, lack of social reciprocity). No statement can be found as to exclusionary criteria. To train a dog to perform such service functions, there is an intense and lengthy period of instruction. Once selected, a trainer and family work together to habituate the dog to the family and child with autism, train the parents on the commands that will be given to the dog, and to assimilate the dog into the family routine. The popularity of such a support appears to be increasing. Several of the agencies claim to have a waiting list. For example, National Service Dogs is constructing a new facility for training and education, and eventually will be able to place 40 dogs annually and will be able to expand outside Canada. Since 1996, this one organization has placed over 170 dogs. As with many strategies and treatments when it comes to autism therapy, one must ask whether or not there is evidence of effectiveness of autism dogs providing the services advocates claim they provide. To review, there seems to be two primary positive outcomes in the literature –the dogs provide enhanced physical safety and security, and the dogs cause enhanced social, learning, and emotional improvements. When reviewing the literature for research on the effect of autism dogs, there are many testimonials, some case studies, and only a few actual studies incorporating anything resembling a form of research design. Most of the research done on this topic consists of qualitative research, involving interviewing as the means for collecting data. Thus, the quality and validity of the information collected on ascertaining the effects of the autism dogs must be viewed cautiously. Nevertheless, with regards to the dogs providing increased physical safety and security, most of the outcome studies support the notion that these dogs fulfill that function. For example, Burrows and Adams (2005) and Burrows, Adams and Millman (2008) reported that parents consistently claimed that the dogs prevented children from bolting and running away. Parents relaxed more during bedtime knowing that the dogs would alert them should the child with autism leave the bed or exhibit some other potentially dangerous behavior. Because of the dog’s ability to physically prevent the child with autism from behaving in a dangerous way, parents felt more in control and calmer. Most of the dogs accepted the jackets in which they were placed and followed commands well. Parents reported immediate satisfaction and reduction in concerns about safety issues. The research is less convincing when attempting to definitively answer the question as to whether the presence of the autism dog results in the learning of new skills, the improvement of emotional status, increased socialization, and fewer behavioral concerns. Some parents noticed new skill development. For example, after being with their dog for a period of time, some children began regulating walking pace and developing improved motor skills and control. Burrows, et al. (2008a) found that some of their participants began learning dog-care tasks (e.g., feeding the dog by taking lid off food container; putting food in bowl; putting bowl on floor; commanding dog to eat). Additionally, motor skills improved in some children who learned to pet the dog. The authors also found that, according to parents, the children exhibited decreased anxiety, were calmer, and engaged in fewer tantrums and other disruptive behaviors. Some parents even reported improved bedtime routines, and that the children “just seemed happier.” Using a more sophisticated design, Farnum and Martin (2002) investigated the impact of such dogs on the mood and social abilities of children with autism. Using an ABCA design, the researchers systematically varied three different conditions consisting of a simple toy, stuffed dog, and real dog. They found that the participants demonstrated greater positive mood and “focus” on the environment when in the presence of the autism dog. However, this study has not been replicated and there are some methodological issues that limit the validity and generalization of the conclusions. Interestingly, Burrows, et al. (2008b) also studied the impact of several variables on the dogs themselves. The authors conducted a series of interviews with members of 11 families who used dogs for their persons with autism. Parents were interviewed at three different time periods – when they were receiving training about their new dog, and every third month for 6 months. The authors reported that generally speaking, the dogs were generally loved and bonded well with all members of the family. But the dogs were placed under significant stress, given the peculiarities of being with a child with autism. For example, some dogs could not sleep for long periods of time, if a child with autism went without sleep. Some dogs spent long hours in their jackets and inhibited urination and defecation if accompanying the child to school. Some children engaged in aggression towards the dogs, causing dogs to startle and move away from the child. The authors reported that some dogs eventually learned the cues that the child might suddenly display inappropriate behavior, or learned to discriminate between cries of needing something and cries that would signal aggression or tantrum. The authors also discussed their results in terms of the impact of the dogs on social interactions. Generally speaking, dogs developed a primary relationship with one or both parents, and to a lesser extent, the child with autism (also supported by Burrows, et al. 2008a). Only four of the children with autism showed interest in the dog, defined as petting or initiating any sort of social approach. Dogs preferred interactions with parents and followed their commands. Generally, the child with autism provided less attention and social contact with the dog than did other family members. Conclusions The evidence is less compelling when considering whether the autism dogs themselves are the reason for increased learning in the areas of motor, emotion, social, or adaptive behavior areas. They do not have any special capacity or “sense” of a special emotional connection with persons with autism. Rather, dogs can be the medium in which the child practices skills, such as learning to feed the dog. However, the reason for learning is most likely the repeated practice instead of any special characteristic of the animal. In addition, the other areas of improvement noted in these qualitative studies – such as the children happier, engaging more in positive social interactions, and displaying reduced number of tantrums – cannot be confidently believed, due to the data collection methodology and lack of reliability and validity of those data. Autism dogs seem to have a role to play for the physical security and safety of children with autism. And that reason alone may be powerful enough to consider using one if it can be financially afforded. The impact of the dog on learning and other behavior remains to be determined in a more rigorous manner, and until that time, the use of autism dogs should be limited to enhancing safety of the child.
References Autism Service Dogs (2011). Retrieved October 18, 2011 at http://autismservicedogsofamerica.com/ Burrows, K. E., & Adams, C. L. (2005). Evaluating the benefits of service dogs for children with autism spectrum disorders. Retrieved on October 21, 2001 at www.cnaf.net/documents/NationalServiceDogsStudy.pdf Burrows, K. E., Adams, C. L., & Millman, S. T. (2008a). Factors affecting behavior and welfare of service dogs for children with autism spectrum disorder. Journal of Applied Animal Welfare Science, 11, 42-62. Burrows, K. E., Adams, C. L., & Spiers, J. (2008b). Sentinels of safety: Service dogs ensure safety and enhance freedom and well-being for families with autistic children. Qualitative Health Research, 18(12), 1642-1649. Hall, P. L., & Malpus, Z. (2000). Pets as therapy: Effects on social interaction in long- stay psychiatry. British Journal of Nursing, 9(21), 2220-2225. McNicholas, J. & Collis, G. M. (2000). Dogs as catalysts for social interactions: Robustness of the effect. British Journal of Psychology, 91, 61-70.
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| Last Updated on Monday, 04 June 2012 19:48 |