Richard J. Cowan, Ph.D., NCSP Kent State University

1. Overview of the National Autism Center’s National Standards Report: An Update on “Best Practices” Richard J. Cowan, Ph.D., NCSP Kent State University

2. Evidence-Based Interventions Questionable Vs. Promising National Standards Project “Best Practices”

3. Approaches to Intervention • Attitudes, values, and beliefs shape our approach to working with children who demonstrate disruptive behaviors • Our approach to working with children is also influenced by what we know about various schools of thought about behavior explanations (e.g., psychodynamic vs. behavioral)

4. Approaches to Intervention (continued) • Psychodynamic/Psychoanalytic • Relates back to childhood • “couch therapy” • Medical/Biological • Prescriptions • Over the counter agents • Behavioral/Educational • Arranging antecedents and consequences • Comprehensive Approach

5. How to Determine the Best Approach • Start with evidence-based interventions • Research shows the treatment made a statistically significant change in children’s behavior—statistically significant vs. clinically significant • Find evidence-based practices in professional journals or ask experts—but ask experts to tell you what the research shows about the effectiveness of the intervention.

6. Levels of Research/Evidence of Effectiveness • Questionable interventions • Although there is a clear lack of scientific evidence, these interventions continue to be promoted • Promising interventions • There exists some research to support the effectiveness of these interventions; however, we still need to approach them with caution and make sure they are applicable to this child in this situation

7. Psychoanalysis Sensory Integration Therapy Auditory Integration Therapy Equestrian Therapy Dolphin Therapy Holding Therapy Options Therapy Rapid Prompting Neurological Reprogramming Questionable Interventions Refuted Intervention: Facilitated Communication Herbert et al., 2002; National Research Council, 2001

8. Social Stories Sensory Diets Floor Time(Greenspan) Diets/Vitamins/Supplements Chelation Therapy(removing toxins) Recreational Therapies Aquatic, Art, Music, etc. Relationship Development Intervention (RDI) Focuses on transition, relaxation and flow Questionable Interventions (cont’d) Herbert et al., 2002; National Research Council, 2001

9. Promising Interventions • Applied Behavior Analysis (ABA) • Positive Reinforcement • Negative Reinforcement • Differential Reinforcement • Planned Ignoring + Positive Reinforcement • Token Economy Systems • Discrete trial training • Thousands of studies demonstrating efficacy of ABA-based interventions for individuals with disruptive behavior (Maurice, Green, & Luce, 1996, 2001)

10. Promising Interventions • Discrete Trial Training • Not just Lovaas (analog) discrete trial training • There exists a range of evidence-based approaches to DTT (Analog – Naturalistic) • Naturalistic approaches to DTT have proven equally effective as analog approached • In addition, generalization and spontaneity are enhanced, as compared to analog approaches alone

11. Promising Interventions • Educational Interventions • TEACCH (Teaching and Education of Autistic and related Communication handicapped Children) • PECS (Picture Exchange Communication System) • Comprehensive Programs • Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP) • Denver Health Sciences Program • Medical Interventions • Think about the implications of medical interventions as a “ready to learn” process

12. Medical Interventions • Stimulants, SSRI’s, and other classes of medication • These are helpful for TREATING SYMPTOMS • Each medicine targets a specific symptom/set of symptoms; however, there is no cure for autism! • What is our role in medical intervention? • Making sure the child takes his/her medication to maximize performance in the classroom • Monitoring the symptoms associated with the medication to help make decisions about the effectiveness of meds • Making certain that you view medication as one component in a comprehensive approach to education

13. Recommended PracticeNational Research Council (2001) “Effective preschool programs for children with ASD include: • Entry into intervention programs as soon as the diagnosis is suspected, • Active engagement in intensive instructional programming for a minimum of the equivalent of a full school day, 5 days a week (at least 25 hours a week), with full year programming varied according to the child’s chronological age and developmental level, • Repeated, planned teaching opportunities generally organized around relatively brief periods of time for the youngest of children (e.g., 15-20 minute intervals), including sufficient amounts of adult attention in one-on-one and very small group instruction to meet individualized goals,

14. Recommended PracticeNational Research Council (2001) (continued) • Inclusion of a family component, including parent training, • Low student/teacher ratios (no more than two young children with ASD per adult in the classroom), and • Mechanisms for ongoing program evaluation and assessment of individualized children’s progress, with results translated into adjustments in programming” (p. 175) http://www.nationalacademies.org/nrc/ http://www4.nationalacademies.org/news.nsf/isbn/0309075777?OpenDocument

15. Additional RecommendationsNational Research Council (2001) • Sufficient individual attention every day so that Individual Family Service Plan (IFSP) and Individualized Education Program (IEP) objectives may be addressed with adequate intensity • Successful interactions with typically-developing children • Instruction in the areas of functional spontaneous communication, social interaction, play skills, and cognitive skills taught in a manner to facilitate generalization, proactive and effective approaches to challenging behavior, and functional academic skills

16. Evidence-Based Interventions Questionable Vs. Promising National Standards Project “Best Practices”

17. National Standards Project (NSP)(National Autism Center, 2009) • The major goal of the NSP is to serve as a single guide for parents, caregivers, educators, and service providers • Additionally, the NSP aims to: • Provide the strength of evidence supporting educational and behavioral treatments that target core characteristics • Describe the age, diagnosis, and skills/behaviors targeted for improvement associated with treatment options • Identify the limitations of the current body of research on autism treatment • Offer recommendations for engaging in evidence-based practice for ASD

18. What is the purpose of the National Standards Project? • To identify the level of research support currently available for educational and behavioral interventions used with individuals with ASD (up to age 22). • To help families, educators, and service providers understand how to integrate critical information in making treatment decisions. • To identify limitations of the existing research involving individuals with ASD. (NAC, 2009)

19. Findings: Three Levels of Evidence • “Established” (total of 11 treatments) • Produce beneficial outcomes • Known to be effective for individuals on the autism spectrum • Overwhelming majority of these interventions were developed in the behavioral literature (e.g., applied behavior analysis, behavioral psychology, and positive behavior support). • “Emerging” (total of 22 treatments) • Have some evidence of effectiveness, but not enough for us to be confident that they are truly effective • “Unestablished” (total of 5 treatments) • There is no sound evidence of effectiveness (NAC, 2009)

20. Established • Antecedent Package (99 Studies) • Behavioral Package (231 Studies) • Comprehensive Behavioral Treatment for Young Children (22 Studies) • Joint Attention Intervention (6 Studies) • Modeling (50 Studies) • Naturalistic Teaching Strategies (32 Studies) • Peer Training Package (33 Studies) • Pivotal Response Treatment (14 Studies) • Schedules (12 Studies) • Self-Management (21 Studies) • Story-Based Intervention Package (21 studies) (NAC, 2009)

21. Antecedent Package • The modification of situational events that typically precede the occurrence of a target behavior • Alterations are made to increase the likelihood of success or reduce the likelihood of problems occurring • Treatments falling into this category reflect the fields of applied behavior analysis (ABA), behavioral psychology, and positive behavior supports (PBS) (NAC, 2009)

22. Behavior chain interruption Behavioral momentum Choice Contriving motivational operations Cueing and prompting/prompt fading procedures Environmental enrichment Environmental modification of task demands, social comments, adult presence, inter-trial interval, seating, and familiarity with stimuli Errorless learning Errorless compliance Habit reversal Incorporating echolalia, special interests, thematic activities, or ritualistic/obsessive activities into tasks Antecedent Package (Cont’d) (NAC, 2009)

23. Behavioral sleep package Behavioral toilet training/dry bed training Chaining Contingency contracting Contingency mapping Differential reinforcement strategies Discrete trial teaching Behavioral Package • Designed to reduce problem behavior and teach functional alternative behaviors or skills through the application of basic principles of behavior change • Treatments falling into this category reflect the fields of applied behavior analysis, behavioral psychology, and positive behavior supports • Examples include: (NAC, 2009)

24. Functional communication training Generalization training Mand training Noncontingent escape with instructional fading Progressive relaxation Reinforcement Scheduled awakenings Shaping Stimulus pairing with reinforcement Successive approximation Task analysis Token economy Behavioral Package (Cont’d) • Examples include:

25. Comprehensive Behavioral Treatment for Young Children (CBTYC)* • Reflects research from comprehensive treatment programs that involve a combination of applied behavior analytic which are delivered to young children in a variety of settings and involve a low student-to-teacher ratio • All studies falling into this category met the strict criteria of: • Targeting the defining symptoms of ASD • Having treatment manuals • Providing treatment with a high degree of intensity • Measuring the overall effectiveness of the program (i.e., studies that measure subcomponents of the program are listed elsewhere in this report) *These treatment programs may also be referred to as ABA programs, behavioral inclusive programs, or early intensive behavioral intervention

26. Naturalistic Teaching Strategies • Primarily child-directed interactions used to teach functional skills in the natural environment • Often involve: • Providing a stimulating environment • Modeling how to play • Encouraging conversation • Providing choices and direct/natural reinforcers • Rewarding reasonable attempts • Examples include: • Incidental teaching • Milieu teaching • Embedded teaching • Prelinguistic milieu teaching (NAC, 2009)

27. Pivotal Response Treatment* • Focus on targeting “pivotal” skills: • Motivation to engage in social communication • Self-initiation • Self-management • Responsiveness to multiple cues • Goal of very widespread and fluently integrated collateral improvements • Also includes: • Parent involvement in the intervention delivery • Implementation in the natural environment *This treatment is an expansion of Natural Language Paradigm

28. Story-Based Intervention Package • Involve a written description of the situations under which specific behaviors are expected to occur • Stories may be supplemented with: • Prompting • Reinforcement • Discussion • Etc. • Social Stories™ are the most well-known story-based interventions • They seek to answer the “who,” “what,” “when,” “where,” and “why” in order to improve perspective-taking. (NAC, 2009)

29. Second Level of Evidence: Emerging • Augmentative and Alternative Communication Device (14 studies) • Cognitive Behavioral Intervention Package (3 studies) • Developmental Relationship-based Treatment (7 studies) • Exercise (4 studies) • Exposure Package ( 4 studies) • Imitation-based Interaction (6 studies) • Initiation Training (7 studies) • Language Training-Production (13 studies) • Language Training-Production & Understanding) (7 studies) • Massage/Touch Therapy (2 studies) (NAC, 2009)

30. Emerging (Second Level, Cont’d) • Multi-component Package (10 studies) • Music Therapy (6 studies) • Peer-mediated Instructional Arrangement (11 studies) • Picture Exchange Communication System (13 studies) • Reductive Package (33 studies) • Scripting (6 studies) • Sign Instruction (11 studies) • Social Communication Intervention (5 studies) • Social Skills Package (16 studies) • Structured Teaching (4 studies) • Technology-based Treatment (19 studies) • Theory of Mind Training (4 studies) (NAC, 2009)

31. Unestablished Treatments • Academic Interventions (10 studies) • One size fits all; Traditional approaches • Auditory Integration Training (3 studies) • Facilitated Communication (DO NOT USE!) • Gluten- and Casein-Free Diet (3 studies) • Sensory Integrative Package (7 studies) (NAC, 2009)

32. Auditory Integration Training • This intervention involves the presentation of modulated sounds through headphones • Attempts to retrain an individual’s auditory system • The goal is to improve distortions in hearing or sensitivities to sound (NAC, 2009)

33. Gluten- and Casein-Free Diet • These interventions involve elimination of an individual’s intake of naturally occurring proteins gluten and casein • Early studies suggested that the Gluten- and Casein-Free diet may produce favorable outcomes but did not have strong scientific designs • Better controlled research published since 2006 suggests there may be no educational or behavioral benefits for these diets • Potential medically harmful effects have begun to be reported in the literature (NAC, 2009)

34. Sensory Integrative Package • These treatments involve establishing an environment that stimulates or challenges the individual to effectively use all of their senses as a means of addressing overstimulation or understimulation from the environment (NAC, 2009)

35. Evidence-Based Practice (NRC, 2009) • Research Findings • These should be given serious consideration first “because… (a) the treatment produced beneficial effects and (b) they are not associated with unfavorable outcomes” (NRC) • Professional Judgment • This involves input from professionals with established expertise in the treatment and education of individuals with ASD • Data-based decision making is critical!

36. Evidence-Based Practice (NRC, 2009) • Values and Preferences • Treatment contrary to the values of family members • Treatment resulted in ineffective outcomes or undesirable side-effects • Client rights • Capacity • The treatment has never been implemented in an existing system • A “local expert” does not possess formal training in the technique