Jonathan M. Campbell, Ph.D. Department of Educational Psychology University of Georgia

1. Evidence-Based Interventions for Individuals with Autism Spectrum Disorders UT-Memphis ILT - 12.10.2009 Jonathan M. Campbell, Ph.D. Department of Educational Psychology University of Georgia

2. Learning Objectives • Identify and describe essential characteristics of evidence-based interventions. • Identify evidence-based interventions for individuals with autism spectrum disorders. • Understand the role of research synthesis in establishing evidence-based interventions for individuals with autism spectrum disorders.

3. Overview • Re-introduce definitions of “evidence-based intervention” and “evidence-based practice” • Re-introduce information about autism spectrum disorders • Broad review of “evidence-based intervention” for individuals with autism spectrum disorders • Introduce methods of quantitative synthesis to establish “evidence-based intervention”

4. What does “evidence-based” mean? Variety of terms • Evidence-based medicine • Empirically supported treatments • Evidence-based intervention • Evidence-based practice – growing adoption of this term across disciplines

5. What does “evidence-based” mean? • In general, evidence-based practice is a guiding philosophy: • Evidence should guide selection of interventions. • Evidence should be used to evaluate the effects of an intervention. • So, establishing evidence-based interventions is one component of engaging in evidence-based practice.

6. What does “evidence-based” mean? • Evidence-based medicine defined (Sackett et al., 1996; 2000): • the integration of • best research evidence • with clinical expertise • and patient values.

7. What does “evidence-based” mean? • Evidence-based practice in psychology defined: (APA Task Force, 2006): • the integration of • the best available research • with clinical expertise • in the context of patient characteristics, culture, and preferences. (p. 273)

8. “Evidence based” practice is relevant to: • Medicine – Sackett et al. (1996; 2000) • Psychology – Division 12 and APA Task Force on Empirically Supported Treatments (e.g., Chambless & Hollon, 1998; APA Task Force, 2006) • Education – Federal Legislation, Funding • Communication disorders – Schlosser and Sigafoos (2008) • Special Education –Council for Exceptional Children

9. “Evidence based” practice is relevant to: • Educational Research - Federal Funding – Institute of Education Sciences (http://ies.ed.gov) • Created by Education Sciences Reform Act of 2002 with U.S. Dept of Education • Goal: Bring rigorous and relevant research to U.S. education system • National Center on Special Education Research (NCSER: http://ies.ed.gov/ncser)

10. “Evidence-based” practice is relevant to: • Special Education: Council for Exceptional Children (CEC) (www.cec.sped.org) • CEC defining and presenting evidence-based practices in the field of special education. • Special series of methodological papers: • Exceptional Children (2005) • Group experimental designs. • Single subject designs.

11. “Evidence based” practice is relevant to: • Communication disorders – Schlosser and Sigafoos (2008) - EBCAI • Promote EBP. • Facilitate evidence- based decision making in serving individuals with communication impairments.

12. “Evidence based” practice relevant to: • Professional ethical standards require that practice is science-based or evidence-based • American Psychological Association • National Association of School Psychologists • Behavior Analysis Certification Board • Federal legislation – “scientifically based instructional practices” • No Child Left Behind (PL 107-110) • Individuals with Disabilities Education Improvement Act of 2004 (PL 108-446)

13. “Evidence based” practice relevant to: • Insurance companies • Cite evidence-based reviews in decision-making regarding benefits and coverage. • Due to insufficient clinical evidence to support medical efficacy, intensive behavioral therapy/applied behavioral analysis for the treatment of autism spectrum disorders will not be reimbursed by Oxford. This service and/or device is not proven to be clinically effective... • There are limited studies to suggest that use of behavioral interventions, such as intensive behavioral therapy/applied behavioral analysis (Lovaas therapy), in very young children with autism may improve behavior, language skills, and cognitive function; however, the evidence is insufficient to establish a relationship between the intensity and duration of the intervention and degree of improvement in these areas, or to define specific criteria by which to select patients who might benefit from intensive intervention.

14. How does Evidence Based Practice apply to ASD? A Chronology.

15. Present Diagnoses for Autism Spectrum Disorders ASD is newer term for a subset of Pervasive Developmental Disorders (PDD) • Autistic Disorder • Asperger’s Disorder • Pervasive Developmental Disorder-NOS Other PDDs: • Childhood Disintegrative Disorder • Rett’s Syndrome

16. ASDs – General Introductory Info. • Disabilities that are invisible at birth • Complex presentation of symptoms • Show a range of impairments – mild to severe across areas: HETEROGENEITY • Brain structure/function different – e.g., cerebellum; amygdala; fusiform gyrus • Genetics important

17. Areas Affected • Reciprocal social interaction • Communication • Patterns of behaviors and interests • Also: • Sensory sensitivities • Cognitive delays often present

18. Descriptive Statistics for Autism • Prevalence estimates now ~ 1:110 - 500 for all ASDs. • 1 in 150 frequently cited for all ASDs (CDC; February, 2007 6.7/1,000). • Pediatrics (2009) 1:91 all ASDs. • ASDs found in all cultures and SES • More prevalent in males vs. females (4-5:1; e.g., Fombonne, 2005) • 1st concerns 16-20 mos., diagnosis 4-5 yrs (Howlin & Asgharian, 1999) • Mandell et al. (2005): 1st dx – 3.1 years

19. EBI ‘Standards’ • Within ASD literature, variety of standards exist for categorizing an intervention as evidence-based. • Similarities: • Develop rubric for evaluating evidence. • Review literature – inclusion/exclusion. • Classify interventions based on findings and scientific rigor. • Independent replication important.

20. EBI ‘Standards’ • Differences: • Scope of review. • Rubrics differ. • Narrative versus quantitative.

21. EBI ‘Standards’ and Reviews for ASD • Journal of Clinical Child and Adolescent Psychology (1998; 2008): Empirically Supported Treatments • Well-established: • Tx manual; • Clearly specified participants; AND: • Either 2 or > independent well-designed group studies with TX>alternate TX or TX=established • Or, 9 or > well-designed single-subject designs comparing TX to alternate treatment

22. EBI ‘Standards’ and Reviews for ASD • Probably efficacious: • Clearly specified groups. • TX manual preferred, not required, AND • Either, 2 studies showing better outcomes than control. • Or, two well-designed group studies by same investigators with TX>alternate or TX = established TX. • OR, 3 or more single-subject designs with strong design features and compare TX to another TX

23. EBI ‘Standards’ and Reviews for ASD • Possibly efficacious: • At least one “good” study showing treatment to be efficacious

24. EBI ‘Standards’ and Reviews for ASD • J. of Clinical Child Psych (Rogers, 1998): Special Series: ESTs for Children • Well-established: • None. • Probably: • None. • Possibly: • Lovaas’s EIBI; Denver Model; LEAP Program

25. EBI ‘Standards’ and Reviews for ASD • National Research Council’s (2001): Educating Children with Autism • Narrative review. • Effective interventions: • Occur early. • Are intense (25 hr/wk). • Involve planned teaching. • Include family component. • Low student : teacher ratio. • Feature ongoing evaluation.

26. EBI ‘Standards’ and Reviews for ASD • Simpson, R. L. (2005). Autism Spectrum Disorders: Interventions and Treatments for Children and Youth • Narrative review. • Four levels of evidence. • Reviewed 37 interventions according to rubric.

27. EBI ‘Standards’ and Reviews for ASD • Scientifically based practice – “significant and convincing empirical efficacy and support” • Promising practice – “method that appears to have efficacy and utility with individuals with ASD, but requires additional scientific support” • Limited supporting information – “treatments for which there is little or no scientific evidence” • Not recommended – “treatments that lack efficacy and that may have the potential to do harm”

28. EBI ‘Standards’ and Reviews for ASD • 4 Scientifically based practices: ABA; Discrete Trial Training; Pivotal Response Training; LEAP Model • 13 Promising practices: PECS; Structured Teaching (TEACCH); Sensory Integration; Joint attention interventions • 18 Limited supporting information: Pet therapy; Auditory Integration Therapy; Megavitamins; Gluten/casein Diet; Music therapy • 2 Not recommended:Facilitated Communication; Holding Therapy

29. EBI ‘Standards’ and Reviews for ASD • Steele et al. (2008) Handbook of Evidence-Based Therapies for Children and Adolescents • Narrative review. • Campbell et al. • Well-established: • None. • Probably: • Lovaas’s EIBI.

30. EBI ‘Standards’ and Reviews for ASD • J. of Clinical Child and Adol. Psych (Rogers & Vismara, 2008). • Well-established: • Lovaas’s EIBI. • Probably: • None. • Possibly: • Pivotal Response Training.

31. EBI ‘Standards’ and Reviews for ASD National Autism Center (www.nationalautismcenter.org) • National Autism Center Mission (From website): • “to provide leadership and comprehensive evidence-based resources to families, practitioners, and policymakers, to programs and organizations, and to the national community…” • National Standards Project (NSP; 2009): • “The primary goal of the NSP is to provide critical information about which treatments have been shown to be effective for individuals with ASD (below 22 years of age).”

32. EBI ‘Standards’ and Reviews for ASD Methodology ■775 Research Studies reviewed by expert panel using Scientific Merit Rating Scale (SMRS; 0-5 points) 1. Research design – Group: RCT, Power Single-subject: 5 data points per condition 2. Dependent variable (psychometrics; IOA) 3. Independent variable (Integrity >80% for ≥ 25%) 4. Participant eligibility. 5. Generalization of treatment effects – time; setting.

33. EBI ‘Standards’ and Reviews for ASD • Established – Sufficient evidence to confidently determine that treatment produces favorable outcome. • Emerging – One or more studies suggest favorable outcomes; additional high quality studies must consistently demonstrate favorable outcome. • Unestablished – Little or no evidence to draw firm conclusions. Intervention may be effective, ineffective, or harmful. • Ineffective/Harmful – Sufficient evidence exists to determine that a treatment is ineffective or harmful.

34. EBI ‘Standards’ and Reviews for ASD • Established – several published, peer-reviewed studies; SMRS scores of 3 or >; beneficial effects of treatment • Emerging – few published, peer-reviewed studies; SMRS scores of 2; beneficial effects • Unestablished – may/may not be based on research; SMRS scores of 0 or 1; unverified claims; unknown effects based on poorly controlled studies • Ineffective/Harmful – several published, peer-reviewed studies; SMRS scores of 3 or >; no benefit or harm observed

35. EBI ‘Standards’ and Reviews for ASD Results • 11 Established – e.g., behavioral ‘packages (231 studies);’ comprehensive behavioral treatment (22; e.g., Lovaas); joint attention intervention (6); modeling (50; video or live); peer training (33) • 22 Emerging – massage therapy (2); music therapy (6); Picture Exchange Communication System (13) • 5 Unestablished – facilitated communication (5); gluten- / casein-free diet (3); sensory integration packages (7) • Ineffective/Harmful– None.

36. Summary Statements for Reviews Results • EIBI – behaviorally based interventions – consistently rated as supported, most stringent • Variety of interventions that are promising/emerging: • Picture Exchange Communication System; TEACCH; joint attention; • Some agreement on limited support: • Facilitated communication; diets; auditory integration

37. Lovaas’s Early Intensive Behavioral Intervention (EIBI) as a Case Study for Contributions of Meta-analysis

38. What is meta-analysis? • Definition of meta-analysis: • Statistical combining of results from individual studies that address similar research questions • Two General Purposes: • Document effects of treatment (i.e., “Does treatment work? How strong is effect?”) • Examine moderators of treatment effects (i.e., “Does treatment work equally across people? Onset? Intensity?”)

39. What is meta-analysis? • Key measure in meta-analysis is effect size (ES). • ES = summarizes the magnitude of a treatment effect. • For between-group designs, common ES is Cohen’s d: [M Treatment – M Control / SD Pooled] • Effect size interpretation (Z-score): • Small = .2 (Percentile standing = 58th) • Medium = .5 (% ile = 69th) • Larger = .8 (% ile = 79) [For 1.0 = 84th % ile]

40. What is meta-analysis? • For within-subject designs, standardized mean change: [M Post-treatment – M Pre-treatment / SD Pooled Pre and Post]

41. Lovaas’s EIBI Approach • 1:1 intervention, emphasis on discrete trial • 40 hours per week on average for ≥ 2 years • Student therapists and parents • Operant (consequence-based) techniques used to increase appropriate and decrease inappropriate behavior. • Aggression/Self-stim reduced by: ignoring; time-out; DRA; Punishment used as last resort (e.g., “No!”; thigh slap)

42. Lovaas’s EIBI • Year 1 – Focus on reducing self stim and aggression; Build compliance to based verbal requests; Appropriate toy play; Extend treatment to home. • Year 2 – Teach expressive/abstract language, peer play. Extend treatment to community. • Year 3 – Teach emotional expression, preacademic curriculum, observational learning

43. Campbell (2007) • A meta-analysis of published studies of EIBI. • Goals: • (a) to quantify average outcomes of EIBI in: IQ, language, adaptive functioning, and autism symptomatology, • (b) to test for hypothesized moderators of treatment outcomes in the domain of IQ, such as: pretreatment IQ, age at enrollment, intensity of treatment, and length of treatment.

44. Table 1. Description of participants. Within-subject designs.

45. Table 2. Description of participants. Between-subject designs.

46. Figure 1. Boxplot of IQ effect sizes divided by design.

47. Figure 2. Relationship b/t intake IQ and IQ effects

48. Figure 3. Relationship b/t hours/ week and IQ effects

49. Conclusions from the synthesis • EIBI yielded significant effects across all domains of functioning when compared to control groups. • IQ outcomes were correlated with pretreatment IQ for within-subject designs. • IQ outcomes also appear correlated with pretreatment IQ for between-subject designs. • Age of treatment onset, treatment intensity, and treatment length did not appear to correlate with IQ outcomes.

50. Other recently conducted meta-analyses • Reichow and Wolery (2009). • Presented findings for within and between subject designs. • 13 studies included in within-subject analysis. (4 more than Campbell, 2007)