Evaluating Treatments for Children with Autism

1
Evaluating Treatments for Children with Autism

• Ed553
• Applied Behavior Analysis Programs
• Caldwell College

2
Science and Assessing Effective Treatment

• Science provides certain criteria to decide what
  information is, and is not, valid (accurate)
• Certain characteristics can be seen in
  treatments that are likely NOT scientifically
  validated
• In this presentation, we will use the terms
  TREATMENT, THERAPY, and INTERVENTION
  interchangeably

3
How do I Evaluate Treatment Claims?Psuedoscientif
ic Therapies Some Warning Signsoriginally
printed in Science in Autism Treatment, Spring
1999.

• High "success" claimed without valid supporting
  evidence
• Rapid effects promised
• Therapy said to be effective for many symptoms or
  disorders without evidence that you can
  generalize these effects
• Theory behind the therapy contradicts objective
  knowledge (and, sometimes, common sense)
• Therapy said to be easy to administer, requiring
  little training or expertise

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How do I Evaluate Treatment Claims?

• Other currently validated treatments are said to
  be unnecessary, inferior, or harmful.
• Promoters of the therapy work outside their area
  of expertise.
• Only testimonials, anecdotes, or personal
  accounts are offered in support of claims about
  the therapy's effectiveness. Little or no
  objective evidence is provided.
• Catchy, emotionally appealing slogans are used in
  marketing the therapy.
• Belief and faith are said to be necessary for the
  therapy to "work."

5
How do I Evaluate Treatment Claims?

• Skepticism and critical evaluation are said to
  make the therapy's effects evaporate.
• Promoters resist objective evaluation and
  scrutiny of the therapy by others.
• Negative findings from scientific studies are
  ignored or dismissed.
• Critics and scientific investigators are often
  met with hostility, and are accused of
  persecuting the promoters, being "close-minded,"
  or having some ulterior motive for "debunking"
  the therapy.

6
MoreHow do I Evaluate Treatment Claims?

• Source American Academy of Pediatrics Committee
  on Children with Disabilities
• Treatment is based on overly simplified
  scientific theories (e. g., certain sounds can
  re-organize the brain)
• Treatment fails to identify specific treatment
  objectives or target behaviors
• Treatments are stated to have no adverse effects
  without supporting evidence thus, proponents
  deny the need to conduct controlled studies
• (This contradicts ALL ethical codes, which
  require First, do no harm!)

7
Sensory Integration Therapy

• Sensory Integration (SI) therapy is a
  sensory-motor treatment developed by Dr. A. Jean
  Ayres.
• Proponents theorize that sensory integration is
  an innate neurobiological process
  (Hatch-Rasmussen, 1995), and that children with
  autism and other developmental delays experience
  dysfunction in which sensory input is not
  integrated or organized appropriately by the
  brain.

8
Evaluating Sensory Integration Therapy

• Current research does not support SI as an
  effective treatment for children with autism,
  developmental delays or mental retardation
• SI has not been shown to be responsible for
  positive change in a child's behaviors or skills.
• In at least one study, SI was shown to actually
  increase self-injurious behaviors.
• Association for Science in Autism Treatment

9
Evaluating Sensory Integration Therapy

• "Though Sensory Integration Therapy does not
  appear to enhance language, control disruptive
  behaviors, or otherwise reduce autistic
  behaviors, it may offer enjoyable, healthy
  physical activity (Smith, 1996).
• Professionals considering SI interventions
  should portray the intervention as experimental,
  and disclose this status to key decision makers
  influencing the child's intervention.
• Association for Science in Autism Treatment

10
Auditory Integration Training

• Developed in 1960s by French physician Guy Berard
• AIT is based on unproven theory that symptoms in
  autism are caused by auditory perception defects
  that distort sound or produce auditory
  hypersensitivity (hyperacusis).
• Treatment consists of identification of sound
  distortion or hypersensitivity followed by twice
  daily sessions for 2 weeks in which computer
  modified music determined to be optimum for the
  patient is played through a device called the
  Audiokinetron.

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Concerns

• Audiokinetron may potentially be unsafe,
  delivering levels of sound to the eardrum that
  may be harmful to hearing.
• AIT devices do not have FDA approval for treating
  autism or any other medical problem.
• The FDA has banned the importation of the
  Electric Ear and any other AIT device made by
  Tomatis International, of Paris, France.

12
Evaluating Auditory Integration Therapy

• No well-designed scientific studies demonstrate
  that AIT is useful (in any form including
  Tomatis) therefore AIT is not recommended for
  children with autism.
• The American Academy of Pediatrics
• The American Academy of Audiology

13
Evaluating Auditory Integration Therapy

• AIT is not yet objectively substantiated as
  effective subject to the rigors of good science.
• Professionals considering AIT should portray the
  method as experimental, and should disclose this
  status to key decision makers influencing the
  child's intervention.
• Association for Science in Autism Treatment

14
Evaluating Auditory Integration Therapy

• A randomized controlled trial with an adequate
  sample size found no differences in children
  receiving auditory integration training as
  compared with those listening to the same music
  which had not been modified.
• A recent controlled study found no benefit of AIT
  and poorer scores on social and adaptive and
  expressive language scores after AIT.
• Because of the lack of demonstrated efficacy and
  the expense of the intervention, it is
  recommended that auditory integration training
  not be used as an intervention for young children
  with autism.
• New York State Department of Health Early
  Intervention Guidelines

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Claims of Evidence for AIT

• Two studies are offered by AIT proponents which
  do not meet the rigors of scientifically valid
  research
• Gilmor, T. M. (1999). The Efficacy of the Tomatis
  method for Children with Learning and
  Communication Disorders, International Journal of
  Listening, 13, 12.
• This journal does not fit the definition of peer
  reviewed (review by published scientists)
• Conclusions in the paper are based on the
  technique of meta-analysis of past studies
  (conclusions drawn from selected pieces of many
  studies) not empirically validated research.
• Credibility of Journals mother organization
  (International Listening Association) is
  questionable. Web page contains quotes from
  Artists, Writers, and Rock Stars
• "Listen, learn, read from Deep Purple

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Claims of Evidence for AIT

• Second study offered by AIT proponents
• Neysmith-Roy,  J.  M. (2001). The Tomatis Method
  with severely autistic boys Individual case
  studies of behavioral changes, South African
  Journal of Psychology, 31.
• Case study does not qualify as empirically
  validated research. It is a description of
  somebodys characteristics but has no controlled
  assessment of treatment variables.

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Traditional Speech Language Therapies

• Non-behavioral speech and language therapists
  have developed many different treatments (e.g.,
  PROMPT) most of which are aimed at stimulating
  childrens natural interest and ability in
  learning language.
• The treatments usually take place in one-to-one
  sessions held from ½ to 3 hrs per week.

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Evidence of Traditional Speech Language
Therapies

• No scientific studies have evaluated whether any
  form of speech and language therapy, other than
  behavior analysis, helps children with autism.
• There have been no studies to evaluate the
  effectiveness of PROMPT therapy with children
  with autism
• Dr. Rogers at the MIND Institute is currently
  heading up a project comparing PROMPT with other
  models of language
• No outcome data have been produced, as of yet.

19
Evaluating Traditional Speech Language Therapies

• By itself, speech and language therapy is
  probably not intensive enough to be very
  effective.
• However, it may augment other interventions by
  identifying areas that need remediation or
  offering strategies for promoting the use of
  language skills in everyday settings.

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Speech Language Therapies Using ABA

• A variety of behavioral techniques has been shown
  to be effective for increasing and improving
  language and communication in children with
  autism (e.g., activity schedules, audio modeling,
  video modeling, PECS)
• When teaching children with autism, speech and
  language therapy has been shown to be maximally
  effective when delivered using the principles of
  ABA

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What is an Integrated Treatment Model?

• (Sometimes referred to as combination model,
  comprehensive model, eclectic model, whole person
  model)
• Using an integrated model assumes there are
  multiple effective therapies that, when combined,
  work even better than the single effective
  therapies.
• Using an integrated model also assumes that
  proponents are using only the therapies that have
  been shown to work while ignoring the ones that
  have not.
• But to find out which ones work, you MUST look
  for controlled studies that demonstrate
  effectiveness (use objective data, not
  testimony).
• If this has not been done, then proponents may be
  taking away time from therapies that have been
  shown to be effective by advocating for an
  integrated model
• There is currently NO evidence that combinations
  of therapies for autism are better than the sum
  of their parts.

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Evaluation of Integrated Therapies

• Eikeseth, Smith, Jahr, Eldevik (2002)
• Compared applied behavior analysis (ABA) with an
  integrated treatment
• ABA treatment consisted of language, social,
  academic, fine/gross motor, and self-help skills
• Integrated treatment consisted of sensory
  integration therapy, speech therapy, and ABA
• At a 1-year evaluation, 13 children who had
  received ABA treatment made significantly larger
  improvements than a comparison group of 12
  children who had receive intensive, integrated
  therapy.
• On average the ABA group gained 17 points in IQ,
  13 points in language comprehension, 23 points in
  expressive language, and 11 points in adaptive
  behavior.

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Greenspan (DIR Floortime)

• Stanley Greenspan, MD and colleagues have
  published papers on theories of child
  development.
• Only one relates specifically to children with
  autism others may include references to autism
  among an array of disabilities.
• Greenspan and others have created a
  developmental approach for early intervention
  with children with disabilities (Developmental
  Individual-Difference, Relationship-Based Model)
  commonly referred to as the "Floor Time" approach
  (Greenspan, 1998).

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Greenspan (DIR Floortime)

• DIR/Floor Time includes interactive experiences,
  which are child-directed, in a low stimulus
  environment, ranging from two to five hours a
  day.
• During a preschool program, DIR/Floor Time
  includes integration with typically-developing
  peers.
• Greenspan contends that interactive play, in
  which the adult follows the child's lead, will
  encourage the child to "want" to relate to the
  outside world. (Greenspan, 1998).

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Evaluating Greenspan therapy

• There have been no peer-reviewed, published
  studies of Greenspan's DIR/Floor Time's
  effectiveness for children with autism.
  Professionals considering Greenspan's Floor Time
  should portray the method as without
  peer-reviewed scientific evaluation, and should
  disclose this status to key decision makers
  influencing the child's intervention.
• Association for Science in Autism Treatment

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Evaluating Greenspan therapy

• There are no adequate controlled trials that
  have evaluated the efficacy of intervention
  approaches based on the DIR model for treating
  young children with autism
• Approaches based on the DIR model can be time
  intensive for both professionals and parents and
  may take time away from other therapies that have
  been demonstrated to be effective
• New York State Department of Health Early
  Intervention Guidelines

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Miller Method

• The Miller Method uses adaptive equipment,
  including platforms (that elevate the child in
  hopes of increasing eye contact), large swinging
  balls (to expand the child's reality system), and
  Swiss cheese boards (to teach motor planning, as
  well as to increase the child's understanding of
  his or her relation to environment and space.)
  (Miller, 1998).

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Evaluation of Miller Method

• The Miller Method may have promise, but it is
  not yet objectively substantiated as effective
  subject to the rigors of good science.
• Professionals considering the Miller Method
  should portray the method as experimental, and
  should disclose this status to key decision
  makers influencing the child's intervention.
• Association for Science in Autism Treatment

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Nutritional Supplements and Megavitamin Therapy

• Anecdotal and case reports have generated
  interest in the use of a variety of nutritional
  supplements to treat children with ASD.
• Studies have shown mixed results
• Some studies have been criticized for their
  methodological shortcomings and failure to
  address the issue of safety of use.

30
Elimination diets

• The presence of allergies or food intolerance in
  children often stimulates families to explore
  unconventional diets.
• Recent investigations failed to document a higher
  prevalence of hypersensitivity to common food
  allergens in children with autism compared with
  controls.

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Immune Globulin therapy

• There is some evidence for immunologic
  abnormalities in small numbers of children with
  autism including abnormalities of T cells, B
  cells, natural killer cells, and the complement
  system
• In a study of 20 children with ASD, 10 who
  received intravenous immune globulin for a
  6-month period reportedly demonstrated
  improvements in social behavior, eye contact,
  echolalia, and speech articulation.
• Note The investigators did not use standard
  outcome measures and did not state whether
  participants received other concurrent treatments
  during the course of the study.

32
Immune Globulin therapy

• Two recent reports failed to demonstrate
  significant changes in behaviors associated with
  autism in 17 children who received regular
  infusions of immune globulin for a 6-month
  period.
• There is no scientific evidence to justify the
  use of infusions of immune globulin to treat
  children with autism.

33
Secretin

• Anecdotal reports of 3 children whose behaviors
  were seemingly helped by secretin generated much
  publicity and interest in its treatment potential
• Recent studies, however, have failed to
  demonstrate any scientific evidence to justify
  the use of secretin infusion to treat children
  with autism.

34
Chelation Therapy

• Some theorize that autism might be caused by
  early childhood exposure to environmental
  toxicants, particularly mercury
• To date, there are no published studies linking
  mercury exposure to the development of autism or
  demonstrating that children with autism have had
  greater exposure to mercury than have unaffected
  children.

35
Evaluating Chelation Therapy

• Although several chelating agents have been shown
  to accelerate mercury elimination from the body,
  there is no evidence that chelation therapy will
  improve developmental function.
• Moreover, chelating agents can have significant
  toxicity and cause allergic reaction.
• Chelation therapy is therefore not recommended to
  treat autism

36
Applied Behavior Analysis(Behavior Management
Intensive Behavioral Intervention)

• Intensive, behavioral intervention early in life
  can increase the ability of the child with autism
  to acquire language and ability to learn.
• Thirty years of research demonstrated the
  efficacy of applied behavioral methods in
  reducing inappropriate behavior and in increasing
  communication, learning, and appropriate social
  behavior. A well-designed study of a psychosocial
  intervention was carried out by Lovaas and
  colleagues (Lovaas, 1987 McEachin et al., 1993).
  Up to this point, a number of other research
  groups have provided at least a partial
  replication of the Lovaas model (see Rogers,
  1998).
• U.S. Surgeon General David Satcher, M.D., Ph.D.

37
Applied Behavior Analysis

• All programs educating children with autism
  should include intensive behavioral interventions
  and year-round education.
• The US Dept. of Education and the
• National Research Council's Report
• 'Educating Children with Autism
• Since intensive behavioral programs appear to be
  effective in young children with autism, it is
  recommended that principles of applied behavior
  analysis and behavioral intervention strategies
  be included as an important element of any
  intervention program.
• NYS Department of Health Early Intervention
• Clinical Practice Guidelines

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References

• American Academy of Pediatrics Committee on
  Children With Disabilities. (2001). Technical
  Report The Pediatrician's Role in the Diagnosis
  and Management of Autistic Spectrum Disorder in
  Children, Pediatrics, 107(5).
• Fenske, E. C., Zalenski, S., Krantz, P. J.,
  McClannahan, L. E. (1985). Age of intervention
  and treatment outcome for autistic children in a
  comprehensive intervention program. Analysis and
  Intervention in Developmental Disabilities, 5,
  49-58.

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References

• Jacobson, J. W. (2001). Early intensive
  behavioral intervention Emergence of a
  consumer-driven service model. The Behavior
  Analyst, 23(2), 149-171.
• McEachin, J. J, Smith, T., Lovaas, O. I.
  (1993). Long term outcome for children with
  autism who received early intensive behavioral
  treatment. American Journal on Mental
  Retardation, 97(4), 359-372.
• Smith, T. (1993). Autism. In T. Giles (Ed.),
  Handbook of effective psychotherapy (pp.
  107-133). NY Plenum Press.

40
ABA Resources

• Books
• Handleman, J. S., Harris, S. L. (2001).
  Preschool education programs for children with
  autism. Austin, TX Pro-Ed.
• Harris, S. L., Weiss, M. J., (1998). Right from
  the start Behavioral intervention for young
  children with autism. Bethesda, MD Woodbine
  House.
• McClannahan, L. E., Krantz, P. J. (1999).
  Activity schedules for children with autism
  Teaching independent behavior. Bethesda, MD
  Woodbine House.

41
ABA Resources

• Books
• Leaf, R., McEachin, J. (Eds.). (1999). A work
  in progress Behavior management strategies and a
  curriculum for intensive behavioral treatment of
  autism. New York DRL Books.
• Lovaas, O. I. (2002). Teaching individuals with
  developmental delays Basic intervention
  techniques. Austin, TX Pro-Ed.
• Maurice, C., Green, G., Fox, R. M. (Eds.).
  (2001). Making a difference Behavioral
  intervention for autism. Austin, TX Pro-Ed.
• Maurice, C., Green, G., Luce, S. C. (Eds.).
  (1996). Behavioral intervention for young
  children with autism. Austin, TX Pro-Ed.

42
ABA Resources

• Websites
• NY State Guidelines
• www.health.state.ny.us/nysdoh/eip/autism/autism.ht
  m
• - Behavior Analysis Certification Board
• www.bacb.com
• General Information about Autism
• www.asatonline.org/autism_info.html
• www.behavior.org/autism/
• pediatrics.aappublications.org/cgi/reprint/107/5/e
  85.pdf
• books.nap.edu/books/0309072697/html/index.html