Moving Beyond the I ntensive Behavioral Treatment Vs. Eclectic Dichotomy: Evidence-Based - PowerPoint Presentation

1. Moving Beyond the Intensive Behavioral Treatment Vs. Eclectic Dichotomy: Evidence-Based Programs for Students with ASDSamuel L. OdomUniversity of North Carolina

2. Preview of PresentationIncrease in ASD prevalence creates demand for servicesComprehensive treatment models Comparison of two comprehensive treatment models for preschool childrenPropose a technical, eclectic approach as one alternativeRequire identification of EBPsEfficacy research on the technical, eclectic approach as future research

3. Autism MystiqueProbably more than any disability, or unique set of abilities, autism has been shrouded in a treatment mystiqueThe etiology has gone from refrigerator mothers to epigeneticsTreatments are more diverse than any known disabilitiesTreatment claims range from amelioration to recovery

4. Defense Against the Dark ArtsMany interventions with no scientific evidence have been recommended for children with ASD

5. Cutting Edge Interventions for Autism (Seri & Lyons, 2012)?Antifungal treatmentAquatic therapyAuditory Integration TherapyChelation Removal of Toxic MetalsCraniosacral and chiropractic therapyDietary interventionsHyperbaric oxygen therapyMedicinal marijuanaSensory gymTraditional and indigenous healing Stem cell therapy

6. Discovery and Current Prevalence

7. DSM 5 Diagnostic CriteriaImpairment in social communicationRestricted repetitive and stereotyped patterns of behaviorOnset prior to the age of three years

8. Demographics75% are maleMultiple etiologies related to neurobiological causesUnrelated to socioeconomic status or raceRange of IQ scores, but stretches across the continuum

9. Understanding Intervention Approaches for Learners with ASDFocused Intervention PracticesShorter in durationTarget discrete skillsRepresent the bulk of the evidence-base in the ASD literatureComprehensive Treatment ModelsLonger in durationTarget multiple developmental domainsAt least 30 CTMs & a dearth of empirical evidence for most (Odom, Boyd, Hall, Hume, 2010)

10. History of Disorder and Trends in Treatment in USKanner’s Discovery in 1940sPsychodynamic approaches (Kanner-Bettleheim-Greenspan)Lovaas application of Applied Behavior AnalysisStructured psycho-educational approach (Project TEACCH)

11. Comprehensive Treatment StrategiesMultiple components (e.g., child-focused instruction, family-focused support)Broad scope (i.e., they may address several developmental domain or skill areas)Intensity (i.e., they often occur over an entire instructional day or in multiple settings such as a school/clinic and home)Longevity (i.e., they may occur over months or even years).

12. Review of CTMs 10 identified by National Academy of Science Committee (2002)30 found in review and evaluation in 2010 (Odom, Boyd, Hall, & Hume, 2010)Relative Strong ModelsDenver Model (Early Start Denver Model)LEAPLovaas InstituteMay InstitutePrinceton Child Development InstitutePivotal Response TreatmentEfficacy studies lacking

13. How Unique Are CTMsAlthough CTMs have been described as unique models, there is reason to believe that there are substantial overlapsTEACCH vs. LEAP Treatment Comparison Study (Boyd, Hume…, & Odom, 2013)Review of Intensive Behavior Therapy Programs (Odom, Hume, Boyd, & Stabel, 2012)Position paper on Naturalistic Developmental Behavioral Interventions (Schriebmann et al., 2014)

14. Comparison of Two Model (Boyd, Hume …& Odom, 2014)TEACCH (Treatment and Education of Autistic and related Communication-handicapped Children) Theoretical foundation: Cognitive social learning theoryEmphasis on designing environment that accommodates characteristics of ASDLEAP (Learning Experiences: Alternative Programs for Preschoolers and Parents) Theoretical Foundation: Blend of ABA and high quality early childhood educationEmphasis on individual programs implemented in naturalistic settingsInclusion of nondisabled peers11/14/201414

15. Brief Description of “Control”OverviewTeachers in these programs did not adhere to primarily one theoretical model School administrators and/or teachers helped to identify these classroomsProgrammatic FeaturesTeachers reported using an array of evidence-based practices Some practices included strategies associated with TEACCH (e.g. work systems) or LEAP (e.g., peer-mediated)11/14/201415

16. Study OverviewClasses in North Carolina, Colorado, Florida, and MinnesotaLEAP (22 classes)TEACCH (25 classes)High Quality Control (28 classes)Total participants (198 preschool-age children with ASD)Assessed at Pre and Post on Composite VariablesAutism characteristicsSocial interactionCommunicationSensory and repetitive behaviorFine motor11/14/201416

17. ConclusionsOverview of findings:High fidelity in programs and overlap on fidelity measuresChildren improved over time in all three conditionsOn measures that generated age equivalent: changes in developmental growth over time Interpretation of findings:May reflect importance of programmatic qualityDifficulty of replicating CTM effects when model developer not involvedUse of a “pragmatic” study design Overlap of model components between CTMs

18. Review of IBT and Eclectic Model (Odom, Hume, Boyd, & Stabel, 2012)Among CTMs Intensive Behavior Therapy has the most evidence of efficacyIn studies, these often compared to eclectic programs.Odom et al. (2012) reviewed studies that compared Intensive Behavior Therapy (IBT) with eclectic programs.

19. Brief Review of Recent Studies

20. Key Points from ReviewIBT ProgramsRange of methods characterized IBTOverlap in methods between IBT and EclecticProfessional development and training issuesConstricted setting and age rangePrimarily preschoolLimited or no school-ageEclectic ProgramsThey appear to be using ABA techniques some of the timeThey also appear to be using non-substantiated techniques some of the time

21. Eclecticism and Lessons Learned from Clinical PsychologyMovement to Empirically Supported Treatments in 1990sGilliard, James, & Bowman (1994) discuss the need for an eclectic approach Different forms of eclecticism existsUnsystematic eclecticism: “a jack-of-all-trades-master-of- none approach” (Gilliland et al.,1994, p. 554)Technical eclecticism: selection of empirically supported treatments from different theoretical perspectives for use with an individual client (Lazarus & Beutler, 1993)

22. Stahmer, Schriebman, & Cunningham (2011)Propose a technology of treatment individualization based on Child CharacteristicsFamily CharacteristicsService Setting and SystemPremise: no single treatment works for all children.Some evidence that non-ABA treatments have positive effects Stahmer, A., Schreibman, L., & Cunningham, A. (2011). Toward a technology of treatment individualization for young children with autism spectrum disorders. Brain Research, 1380, 229-239.

23. A Technical Eclectic ApproachImportant to have a conceptual framework or theory of changeNecessary to have a proscribed (manualized) system of assessment, treatment selection, and evaluationNecessary to stay close to the science in selecting interventions

24. Evidence-Based Individualized Program for Students with Autism (EBIPSA)

25. Evidence-Based Practices

26. What Counts as Evidence?

27. Systematic Reviews of the Literature for Evidence Based Practices (EBPs)In 2009, 11 “treatments” or practices with an evidence baseReviewed by National Standard Project from National Autism CenterIn 2010, 24 EBPsNational Professional Development Center (NPDC) Included 10 years, 1997-2007In 2014, 27 EBPs Second review by NPDCIncluded 22 years, 1990-201129,101 possible studies 456 studiesRCT, quasi-experimental, single case designStrength of evidence for assessment Based on number, type of studies using each EBPhtthttp://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/NPDC_CoachingManual.pdfp://autismpdc.Odom, http://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/NPDC_CoachingManual.pdf

28. Current Review: NPDC27 Evidence-Based PracticesAntecedent –Based InterventionsFunctional Communication TrainingPromptingStructured Play GroupsCognitive Behavior InterventionModelingReinforcementTask AnalysisDifferential ReinforcementNaturalistic InterventionsResponse Interruption/ RedirectionTechnology-Aided Instruction/ InterventionDiscrete Trial TeachingParent-Implemented InterventionsScriptingTime DelayExercisePECSSelf-ManagementVideo ModelingExtinctionPeer-Mediated Instruction/ InterventionSocial NarrativeVisual SupportsFunctional Behavioral AssessmentPivotal Response TrainingSocial Skills Training

29. Evidence-Based Practices are Delicious

30. Evidence-Based Individualized Program for Students with Autism (EBIPSA)

31. Quality is Important

32. Learning EnvironmentInterdisciplinary TeamingProgram EcologyStructure & SchedulePositive Learning ClimateCurriculum & InstructionCommunicationSocial CompetencePersonal IndependenceFunctional BehaviorAssessment & IEP Family ParticipationProgram QualityLearner OutcomesTransition (MHS only)

33. Autism Program Environment Rating Scale (APERS) FormatsPreschool-ElementaryInclusion preschoolsSelf-contained preschools K-5 (or beginning of middle school) inclusiveK-5 self containedMiddle School-High SchoolInclusive classes (assumes multiple classes)Self-contained classesTransition programs

34. So, how do you get it into practice?

35. Implementation: The Tie That Binds“…of what a program consists when it is delivered in a particular setting” (Durlak & DuPre, 2008)“…a specified set of activities designed to put into practice a … program of known dimensions, (Fixsen, et al., 2005)“…program delivered to and experienced by participants… and their families (Odom, Hanson, Lieber, Butera, et al., 2008)

36. Fixsen, Blase, Metz, Van Dyke (2013) (Copyright Dean L. Fixsen and Karen A. Blase, 2009; used with permission.)

37. Ongoing Coaching and Technical Assistancehttp://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/NPDC_CoachingManual.pdfRapport and relationshipMutual respectAgreed upon goalsTimeToolsEBP or other practicesFidelity checklistsFeedback Planning

38. ImplicationsPractitioners can build “technical eclectic”/ evidence-supported programsMore research is needed to address focused intervention practices for infants and toddlers with ASD as well as adolescents and young adults with ASDBetter child outcomes dependent on translation of EBPsImplementation scienceProfessional development models

39. National Professional Development Center on Autism Spectrum Disorders A multi-university center to promote use of evidence-based practice for children and adolescents with autism spectrum disordersFPG Child Development Institute, University of North Carolina at Chapel Hill; M.I.N.D. Institute, University of California at Davis Medical Center; Waisman Center, University of Wisconsin at Madison